After the 1994 genocide and collapse of the health system, Rwanda initiated major social and health reforms in order to reduce child mortality and health inequities in accordance with the Millennium Development Goals. The aim of this thesis was to assess trends in under-five mortality (U5M) and equity in child survival, to study social barriers for improved perinatal and neonatal survival, and to evaluate Helping Babies Breathe (HBB), a newborn resuscitation program. In paper I we analysed trends and social inequities in child mortality 1990−2010, using data from national Demographic and Health Surveys conducted in 2000, 2005, and 2010. The following papers were based on hospital studies in the capital of Rwanda. In paper II we explored social inequities in perinatal mortality. Using a perinatal audit approach, paper III assessed factors related to the three delays, which preceded perinatal deaths, and estimates were made of potentially avoidable deaths. Paper IV evaluated knowledge and skills gained and retained by health workers after training in HBB. Under-five mortality declined from the peak of 238 deaths per 1000 live births (95% CI 226 to 251) in 1994 to 65 deaths per 1000 live births (95% CI 61 to 70) in 2010 and concurred with decreased social gaps in child and neonatal survival between rural and urban areas and household wealth groups. Children born to women with no education still had significantly higher under-five mortality. Neonatal mortality also decreased but at a slower rate as compared to infant and U5M. Maternal rural residence or having no health insurance were linked to increased risk of perinatal death. Neither maternal education nor household wealth was associated with perinatal mortality risks. Lack of recognition of pregnancy danger signs and intrapartum-related suboptimal care were major contributors to perinatal deaths, whereof one half was estimated to be potentially avoidable. Knowledge significantly improved after training in HBB. This knowledge was sustained for at least 3 months following training whereas practical skills had declined. These results highlight the need for strengthening coverage of lifesaving interventions giving priority to underserved groups for improved child survival at community as well as at hospital levels.

Σκοπός της παρούσας διατριβής ήταν να μελετηθεί η επίδραση του μηχανικού-ακουστικού ερεθισμού στη βιοφυσική εικόνα του εμβρύου με μια προοπτική τυχαιοποιημένη μελέτη Το υλικό της μελέτης απετέλεσαν γυναίκες με μονήρεις κυήσεις, ηλικία κύησης 30 + 0 εβδομάδες και βιοφυσική εικόνα ≤ 8/10. Οι γυναίκες με τυχαίο τρόπο κατατάσσονταν σε μια από δύο ομάδες. Στην ομάδα Α εφαρμοζόταν ακουστικός ερεθισμός διάρκειας 3 δευτερολέπτων με ένα τεχνητό λάρυγγα. Αν η βιοφυσική εικόνα παρέμενε μη φυσιολογική για 30 λεπτά, ακολουθούσε η εφαρμογή ενός δεύτερου ερεθίσματος, ίδιου με το πρώτο και εκτίμηση της βιοφυσικής εικόνας για ακόμη 30 λεπτά. Στην ομάδα Β ο χρόνος παρατήρησης παρατάθηκε για 60 λεπτά (δύο διαστήματα των 30 λεπτών) , ώστε να συμφωνεί με το χρόνο εξέτασης των γυναικών της ομάδας Α. Οι κυήσεις αντιμετωπίστηκαν με βάση την τελική βαθμολογία της βιοφυσικής εικόνας. Όσες γυναίκες γέννησαν περισσότερο από 24 ώρες από την τελευταία εξέταση δεν περιελήφθησαν στη μελέτη. Τα κριτήρια αξιολόγησης ήταν ενδομήτριος θάνατος, καισαρική τομή για εμβρυϊκή δυσπραγία, βαθμολογία Apgar < 7 στα 5 λεπτά από τον τοκετό, κεχρωσμένο αμνιακό υγρό (από μηκώνιο) και εισαγωγή στη ΜΕΘ νεογνών. Η μηδενική υπόθεση ήταν ότι η εφαρμογή του ακουστικού ερεθισμού δεν μεταβάλλει τις στατιστικές παραμέτρους της δοκιμασίας. Συνολικά 2,833 γυναίκες εισήλθαν στη μελέτη και συγκεκριμένα 1,349 στην ομάδα Α και 1,484 στην ομάδα Β. Η εφαρμογή του ακουστικού ερεθισμού μείωσε σημαντικά τον αριθμό των θετικών δοκιμασιών στην ομάδα Α σε σχέση με την ομάδα Β (4.74% vs. 6.67%, p < 0.05) και αύξησε την επίπτωση των κριτηρίων αξιολόγησης στην υποομάδα των γυναικών με θετική τελική δοκιμασία (positive likelihood ratio: 24.1-CI 95%: 11.12-52.46 vs. 7.52-CI 95%: 4.93-11.46), χωρίς να τροποποιεί το περιγεννητικό αποτέλεσμα. Επιπλέον, η ειδικότητα, η θετική προγνωστική αξία και η ακρίβεια της μεθόδου βελτιώθηκαν σημαντικά στην ομάδα Α,όπως επίσης και η αρνητική προγνωστική αξία για τους ενδομήτριους θανάτους. Συμπερασματικά, η εφαρμογή του μηχανικού-ακουστικού ερεθισμού σε περιπτώσεις που υπάρχει υποψία για εμβρυϊκή δυσπραγία, βελτιώνει την αποτελεσματικότητα της μεθόδου (βιοφυσικής εικόνας), μειώνοντας τις ψευδώς θετικές δοκιμασίες και βελτιώνοντας την ακρίβεια της μεθόδου. Θα πρέπει δε να θεωρείται ως μέσο μιας πιο ενδελεχούς εμβρυϊκής εκτίμησης σε αυτές τις περιπτώσεις. / OBJECTIVES: To verify the effect of vibroacoustic stimulation on biophysical profile score, with a prospective randomised study. STUDY DESIGN: All women with singleton pregnancy, gestational age ≥ 30 weeks, intact membranes and biophysical profile score ≤ 8/10 entered the study, after giving written consent, and were randomised to two groups. In group A, a 3-second stimulus with an artificial larynx was applied; if biophysical profile remained abnormal for 30 minutes, a second stimulus was applied, and it was assessed again. In group B the observation time was extended for 60 minutes to match the time periods of group A. Pregnancies were managed by final test score and patients delivering more than 24 hours apart from last examination were disregarded from the study. Outcome criteria were intrauterine deaths, caesarean sections for fetal distress, Apgar score < 7 at 5 minutes postpartum, meconium-stained amniotic fluid and neonatal intensive care unit admissions. Our null hypothesis was that application of vibroacoustic stimulation does not alter test’s statistical parameters. RESULTS: 1,349 patients were randomised in group A, and 1,484 in group B (2,833 in total). When comparing group A to B, application of vibroacoustic stimulation significantly decreased the number of positive tests (4.74% vs. 6.67%, p < 0.05) and increased the prevalence of outcome criteria in this subgroup (positive likelihood ratio: 24.1-CI 95%: 11.12-52.46 vs. 7.52-CI 95%: 4.93-11.46), without altering perinatal outcome. Furthermore, specificity, positive predictive value and test accuracy were significantly improved, as well as negative predictive value for intrauterine death. CONCLUSION: Vibroacoustic stimulation improves the efficiency of biophysical profile score by decreasing false positive tests and improving test accuracy and should be considered as a means of a more thorough fetal evaluation when fetal compromise is suspected.

Bakgrund Att inducera en förlossning innebär att försöka manipulera igång ett förlossningsarbete i syfte att åstadkomma en vaginal förlossning. Nyttan med induktionen måste alltid överväga riskerna för förlossningskomplikationer. Riksgenomsnittet för inducerade förlossningar var år 2007, 13,2 %. Syfte Kartlägga inducerade förlossningar på en förlossningsklinik i södra Sverige under året 2009. Kartläggningen inbegrep induktionsindikation, använda induktionsmetoder samt förlossningsförlopp och utfall. Metod Retrospektiv observationsstudie där samtliga inducerade förlossningar med levande foster vid induktionsstarten under 2009 på förlossningskliniken inkluderades. Detta gav ett underlag på 306 inducerade förlossningar. Chi-två test och Fisher´s exakta test användes för att testa skillnader i resultatet. Resultat Indikationerna till förlossningsinduktion fördelade sig så att 250 (82 %) utgjorde medicinsk indikation, där vattenavgång utgjorde den främsta anledningen, och 56 (18 %) på humanitär indikation. Det var 220 kvinnor som krävde minst ett upprepat induktionsförsök innan de kom i aktivt förlossningsarbete. Det fanns en signifikant skillnad som talade för att ju högre Bishop score det var vid första induktionsförsöket, desto kortare tid till partus. Förlossningsutfallet blev 71% partus normalis, 18% sectio, 6% vakuum extraktion och 5% partus cum haem. Slutsats Studien visade att det kan finnas anledning för förlossningskliniken att förbättra journalföringen och öka följsamheten av PM vid förlossningsinduktioner. / Background To induce labour means trying to manipulate labour to start in order to achieve vaginal childbirth. The benefits of induction must always outweigh the risk of labour complications. The national average of induced labour in 2007 was 13, 2%. Aim To map induced labours at a childbirth clinic in Southern Sweden during 2009. The mapping included induction indication, used methods of induction, childbirth processes and outcome. Method Retrospective observation study which included all induced labours with living foetuses at the start of induction, at the childbirth clinic during 2009. This gave a basis of 306 induced labours. Chi-squared testing and Fisher’s exact testing was used to test significant differences in the result. Result Indications of labour induction were divided where 250 (82%) constituted medical indication, the water breaking constituting the main reason, and 56 (18%) humanitarian indication. 220 women required at least one repeated induction try before they were in active labour. There was a significant difference indicating that the higher the Bishop Score was at the first induction try, the shorter the time until delivery. Labour outcome was 71% partum normalis, 18% caesarean sections, 6% vacuum extractions and 5% post partum haemorrhages. Conclusion The study showed that there might be reasons to improve the journal keeping and follow the PMs regarding labour induction at the childbirth clinic.

SAMMANFATTNING   Amningen kan ibland vara svår att komma igång med. En del mammor får det att fungera utmärkt medan andra behöver mera stöd. Baby Friendly Hospital Initiative (BFHI) och ”tio steg till lyckad amning” var tänkt att uppmuntra amningen på BB genom åtgärder som utbildning av barnmorskorna i att stödja mammorna. Syftet med denna studie var att beskriva mammors känslor inför amning och deras upplevelse av stöd från personal och pappa under BB-tiden samt att jämföra med en grupp mammor från 1993. Metoden var en kvantitativ tvärsnittsstudie. En enkätstudie genomfördes bland mammor på en förlossningsklinik i Sverige. Deltagande mammor var fördelade på 91 mammor 1993 och 16 mammor 2010. För bearbetning av data användes Statistical Package for the Social Science (SPSS). Resultatet visade att mammorna upplevde en större känsla av osäkerhet och oro 2010 jämfört med 1993. Av mammorna 2010 kände också majoriteten att amning var något de ”måste lära sig”. Mammorna upplevde papporna som mer stödjande 2010 jämfört med 1993. Initiativet till den första amningen togs 2010 i högre grad av en barnmorska än 1993. År 2010 fick en högre andel av mammorna hjälp av personalen på BB vid amningstillfällena jämfört med 1993. Konklusionen är att amningen kunde vara en känslig tid för mammorna och det behövdes stöd. BFHI har haft en positiv effekt på arbetet med att stödja mammorna vid amningen på BB, men det finns fortfarande behov av uppföljning och kontroll av verksamheten. Papporna tar ett större ansvar och är mera stödjande 2010 jämfört med 1993. / ABSTRACT   Sometimes breastfeeding initiating can be hard. Some mothers get a good start others need more support. Baby Friendly Hospital Initiative (BFHI) and “ten steps to successful breastfeeding” were meant to encourage breastfeeding at maternity hospital through measures like education of midwifes in supporting the mothers. The aim of this study was to describe mother’s feelings for breastfeeding and their experience of support from nursing staff and fathers during the stay on BB and to compare with a group of mothers from 1993. The method was a quantitative cross-sectional study. A survey study was accomplished among mothers in a birth-Clinique in Sweden. Participating mothers was 91 in 1993 and 16 in 2010. Statistical Package for the Social Science (SPSS) was used to processing data. The result showed that mothers experienced a greater feeling of uncertainty and anxiety in 2010 compared with 1993. The majority of mothers 2010 also felt that breastfeeding was something they “had to learn”. Mothers experienced that fathers were more supportive in 2010 than 1993. Initiative to the first breastfeeding was in most of the cases in 2010 taken by a midwife and a higher share of the mothers 2010 got help from the nursing staff at breastfeeding time. The conclusion is that breastfeeding might be a sensitive period to the mothers and that support was needed. BFHI has had a positive effect on the work in supporting mother’s breastfeed in the maternity hospital, but there are still needs of following-up and controls of the activity. The fathers took in 2010 more responsibility and are more supporting to the mothers compared with 1993.

Orientador: Cristina Maria Garcia de Lima Parada / Resumo: Aproximadamente 10% das gestantes e 13% das puérperas vivenciam algum transtorno mental, inclusive a depressão, condição que dificulta a vivência da maternidade. Os fatores que levam à depressão perinatal ainda não estão completamente elucidados, em especial aspectos sociodemográficos. O objetivo deste estudo foi investigar a ocorrência e fatores de risco para sintomas depressivos maternos no puerpério imediato. Trata-se de estudo epidemiológico e transversal com 1099 puérperas. A presença de sintomas depressivos foi obtida com a escala Edinburgh Postnatal Depression Scale (EPDS), adotando-se ponto de corte ≥10. Fatores associados aos sintomas depressivos foram investigados por regressão logística múltipla. Houve 6,7% de puérperas com sintomas depressivos. Uso de medicação antidepressiva, violência sofrida na gestação e operação cesariana aumentaram as chances de sintomas depressivos no puerpério imediato em duas, quatro e duas vezes, respectivamente. Reconhecer os sintomas depressivos precocemente, ainda com as puérperas nas maternidades, pode contribuir de forma a reduzir as chances de depressão pós-parto futura, bem como encorajar ações preventivas da equipe de saúde com o cuidado materno e neonatal. / Abstract: About 10% of pregnant women and 13% of the puerperae experience some mental disorder, including depression, a condition that makes the experience of motherhood difficult. The factors that lead to perinatal depression are still not fully elucidated, especially sociodemographic ones. Our objective with this study was to investigate occurrence and risk factors for maternal depressive symptoms in the immediate puerperium. It is an epidemiological and transversal study with 1099 puerperae. We obtained the presence of depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) scale, with a cut-off point of ≥10. Factors associated with depressive symptoms were investigated by multiple logistic regression. There were 6.7% of the puerperae with depressive symptoms. The use of antidepressant medication, gestational violence and cesarean section increased the odds of depressive symptoms in the immediate puerperium in two, four, and two times, respectively. Recognizing depressive symptoms early on, with the puerperae still inside maternity wards, can contribute to reduce the chances of future postpartum depression, as well as encourage preventive actions of the health team with maternal and neonatal care. / Mestre

O presente trabalho procurou analisar a inserção da psicanálise nas novas formas de cuidado terapêutico em perinatologia, mais precisamente, no domínio que envolve os acontecimentos que ocorrem entre a concepção e os 36 meses de vida da criança. Para tanto, inicialmente foi apresentada a área da saúde materno-infantil no Brasil e as políticas públicas que a sustentam. Em seguida, delineou-se o funcionamento do campo escolhido, no caso uma maternidade de alto risco. Tendo em vista, a construção de uma rede de atenção tecida a partir de diferentes olhares, se procurou enfocar os impasses da interseção entre o discurso biomédico, o da educação em saúde e o da psicanálise. Nesse ponto, foi utilizada como referência principal a contribuição de D. W. Winnicott sobre a teoria do amadurecimento pessoal. Com a finalidade de circunscrever o crescente interesse pela primeira infância, procedeu-se a um mapeamento do estudo psicanalítico dos primórdios do psiquismo, após uma breve incursão pelo texto freudiano. Promoveu-se ainda uma discussão sobre o encontro das hipóteses psicanalíticas com as novas descobertas científicas sobre as potencialidades do bebê, ressaltando as consequências possíveis de tal intercâmbio. Por fim, foram destacadas algumas concepções que fundamentam a importância do olhar psicanalítico para o cuidado integral à saúde materno-infantil, enfatizando autores como Lebovici, Cramer, Bydlowski e Golse. Aqui as discussões teóricas entrelaçaram-se com observações de campo e vinhetas clínicas

SAMMANFATTNING  Bakgrund  Depression är vanligt bland unga kvinnor i fertil ålder vilket innebär att barnafödande infaller under en del av livet då många kvinnor är psykisk sårbara. Cirka 10 till 20 procent av alla gravida kvinnor drabbas av depression av varierande grad under den antenatala perioden. Depression ökar risken för tillväxthämning hos fostret, prematur förlossning och postpartum-depression samt försvårar anknytningen mellan mor och barn. Den rådande uppfattningen är att kvinnor som medicinerat med antidepressiva läkemedel innan graviditet bör fortsätta medicinera samt att insättning bör göras när behov finns. Många kvinnor vill dock inte använda antidepressiva läkemedel under graviditet av rädsla för negativ påverkan på fostret och för dessa kvinnor behövs alternativ. I barnmorskans arbete ingår att stödja och vårda kvinnor under graviditet varför kunskap om behandlingsalternativ är vikt för yrkesgruppen.  Syfte Syftet med detta examensarbete var att undersöka vilka icke-farmakologiska behandlingar som finns för depression under graviditet samt dess för- och nackdelar. Metod  En systematisk litteraturstudie har gjorts där 28 artiklar inkluderades av totalt 659 granskade titlar, 110 granskade abstracts och 44 artiklar granskade i sin helhet. De inkluderade artiklarna analyserades med kvalitativ innehållsanalys och kvalitetsgranskades i enlighet med Willman, Stoltz och Bahtsevani, (2016). Resultat  Analysen av studiernas resultat visade attmånga former av ickefarmakologisk behandling kan ha mildrande eller botande effekt vid depression under graviditet. Det framkommer att behandling med yoga, behandling med mind-body terapi, behandling given till par, behandling given digitalt, behandling given i grupp samt behandling med psykoterapi eller samtalsstöd har positiv effekt om än i olika grad.Resultatet ger stöd för att komplement till basprogrammet vid sedvanlig mödrahälsovård är eftersträvansvärt och hjälper kvinnor med antenatal depression och att den positiva effekten ofta kvarstår efter förlossningen. Slutsats  Detta examensarbete visade att många icke-farmakologiska behandlingsmetoder kan hjälpa kvinnor med antenatal depression. Tilltron till behandlingsmetoderna var oftast hög och få negativa effekter framkom. Kvinnor kan utifrån detta informeras om att forskning visat att utöver antidepressiv medicinering finns icke-farmakologiska behandlingsmetoder med god effekt på depression under graviditet. Vidare forskning får visa om behandlingsformerna skulle kunna erbjudas inom ramen för mödrahälsovårdens basprogram, samt om det är möjligt att genom dessa alternativa terapier minska graviditetskomplikationer orsakade av depression. NYCKELORD  Antenatal depression, behandling, depression, graviditet, moderskap, perinatal terapi / ABSTRACT  Background  Depression is common among young women of childbearing age, which means that childbirth occurs during a part of life when many women are mentally vulnerable. About 10 to 20 percent of all pregnant women suffer from depression of varying degree during the antenatal period. Depression increases the risk of growth retardation in the fetus, premature birth and postpartum depression and complicates the bonding between mother and child. The current perception is that women who are taking antidepressants before pregnancy should continue to medicate and that insertation should be made when needed. However, many women do not want to use antidepressant drugs during pregnancy out of fear of adverse affects on the fetus, and for these women more options are needed. Midwifery includes supporting and nursing women during pregnancy, why knowledge about treatment options is important to the occupational group. Purpose  The purpose of this thesis was to investigate the non-pharmacological treatments available in pregnancy depression and their advantages and disadvantages. Method  A systematic review has been made where 28 articles were included in a total of 659 reviewed titles, 110 reviewed abstracts and 44 articles reviewed in full text. The included articles were analyzed with qualitative content analysis and quality assayed according to Willman, Stoltz and Bahtsevani, (2016). Results  The analysis of the results showed that many forms of non-pharmacological treatments may have mitigating or curing effects in the event of depression during pregnancy. It appears that treatment with yoga, treatment with mind-body therapy, treatment given to couples, treatment given digitally, treatment given in a group and treatment with psychotherapy or counseling  has a positive effect, albeit to a different extent. The result provides support for complementing the basic program of customized maternity care, which is desirable and helps women with antenatal depression and that the positive effect often persists after childbirth. Conclusion  This degree project showed that many non-pharmacological treatment methods can help women with antenatal depression. Access to treatment methods was usually high and few negative effects were observed. Women can from this be informed that research has shown that in addition to antidepressant medication there are non-pharmacological treatment methods that have a good effect on depression during pregnancy. Further research can show whether treatment options could be offered within the framework of maternal health care programs, and whether it is possible to reduce pregnancy complications caused by depression through these alternative therapies. KEYWORDS Antenatal depression, depression, maternity, perinatal depression, pregnancy, therapy, treatment

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-13T17:24:00Z No. of bitstreams: 1 TESE RITA NASCIMENTO. 2014.pdf: 1627254 bytes, checksum: f63f2d910510cf11be43ae812800b828 (MD5) / Approved for entry into archive by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-13T18:13:40Z (GMT) No. of bitstreams: 1 TESE RITA NASCIMENTO. 2014.pdf: 1627254 bytes, checksum: f63f2d910510cf11be43ae812800b828 (MD5) / Made available in DSpace on 2014-10-13T18:13:40Z (GMT). No. of bitstreams: 1 TESE RITA NASCIMENTO. 2014.pdf: 1627254 bytes, checksum: f63f2d910510cf11be43ae812800b828 (MD5) / A mortalidade perinatal constitui-se na atualidade um grande desafio para as autoridades no mundo inteiro, em face da dificuldade para evitar estes óbitos, haja vista a complexidade dos fatores de risco. É grande a sua magnitude, mas não tão expressivas são as medidas de prevenção, especialmente nos países menos desenvolvidos. Assim sendo, representa um indicador sensível da qualidade e acesso à assistência obstétrica e neonatal. Esta pesquisa teve como objetivos identificar as áreas de risco, a evitabilidade das causas, os fatores associados à mortalidade perinatal e as desigualdades sociais nesta mortalidade em Salvador, Bahia, no ano de 2007. As unidades de análise foram as 62 áreas de ponderação desta capital soteropolitana. Os dados foram obtidos dos Sistemas de Informação de Nascidos Vivos e sobre Mortalidade, bem como do Censo Demográfico de 2010. A análise estatística foi realizada utilizando os softwares Arc-View, GeoDa, STATA e R. Para análise da evitabilidade, tomou-se como referência a Lista de Causas de Mortes Evitáveis por Intervenções do Sistema Único de Saúde do Brasil. A mortalidade perinatal em Salvador foi elevada no ano em estudo (25,81000/NV) e as maiores taxas se localizaram ao centro e algumas áreas concentradas ao norte, oeste, sul e leste. Não foi detectada dependência espacial para esta mortalidade pela estatística de I de Moran no estudo, a não ser para a mortalidade perinatal evitável pela atenção à gestação, pelo C de Geary, cujas áreas de risco se encontravam ao norte. Quase a totalidade dos óbitos foi evitável (92,1%) e quase metade destes ocorreu pelas causas evitáveis na atenção o parto, sendo a asfixia ao nascer a principal causa (31,5%). Em se tratando dos fatores associados à mortalidade perinatal, baixo peso ao nascer (β = 0,477; p<0,01), raça negra (β = 0,048; p<0,01) e local de nascimento em hospital público (β = 0,026; p<0,01) foram os preditores da variação espacial desta mortalidade. Para a mortalidade perinatal evitável, independentemente do local de nascimento, os recém- nascidos foram expostos até sete vezes mais ao risco pelo efeito do baixo peso ao nascer. Não houve gradiente na mortalidade perinatal quando analisada por estratos do Índice de Condição de Vida, porém os indicadores socioeconômicos apresentaram risco relativo 71,0% superior para nas áreas de ponderação cuja renda domiciliar per capita era inferior a 2,2 salários mínimos. Este resultado foi similar quando a variável dependente analisada tratou-se da mortalidade perinatal por causa evitável. Os resultados deste estudo demonstraram que a mortalidade perinatal em Salvador teve forte influencia dos fatores sociais, considerando as áreas de risco em locais de infraestrutura precária, as desigualdades de renda e os preditores para a mortalidade perinatal proxy de condições socioeconômicas. Avaliar a mortalidade perinatal com enfoque das áreas de risco, fatores associados, evitabilidade e desigualdades sociais, permitiu melhor compreensão da magnitude desta mortalidade em Salvador e poderá contribuir para orientar estratégias de prevenção. / Nowadays the perinatal mortality constitutes a major challenge for authorities worldwide, due to the difficulty in preventing these deaths, given the complexity risk factors. So great is its magnitude, but not as significant are the preventive measures, especially in less developed countries. Thus, it is a sensitive indicator of the quality and access of obstetric and neonatal care. The aims of this study were to identify risk areas, avoidable causes, risk factors to perinatal mortality and social inequities in this mortality in Salvador, Bahia, Brazil, 2007. The units of analysis were the 62 weighting areas of the capital’s Bahia state. The data were obtained from the Information Live Births and Mortality Systems as well as of the Census 2010. The statistical analysis was performed using the Arc-View, GeoDa, R and STATA softwares. For analysis of avoidability, it was used as reference the List of avoidable causes of deaths due to interventions of the Brazilian Health System. Perinatal mortality was high in Salvador in the year of the study (25.81000/NV) and the highest rates were located in the center and some concentrated areas north, west, south and east. No spatial dependence was found for this mortality by Moran's I statistic, except to preventable perinatal mortality due care during pregnancy, at Geary’s C, whose risk areas were at north. Almost all of the deaths were preventable (92.1 %) and almost half of these occurred by preventable causes in childbirth care, and asphyxia at birth the leading cause (31.5 %). In terms of factors associated with perinatal mortality, low birth weight (β = 0.477; p<0.01), black race (β = 0.048; p<0.01), and place of birth in public hospitals (β = 0.026; p<0.01) were predictors of spatial variation of this mortality. For avoidable perinatal mortality, regardless of place of birth, newborns were exposed until seven times more to risk by the effect of low birth weight. There was no gradient in perinatal mortality when analyzed by stratum index of living conditions, however, socioeconomic indicators showed relative risk 71.0 % higher for the spatial variation of perinatal mortality in the weighting area whose household income was less than 2.2 wages minimum. This result was similar when the dependent variable analyzed was the avoidable perinatal death. The results of this study showed that perinatal mortality in Salvador had strong social factors influence, considering the risk areas in places of poor infrastructure, income inequality and predictors of perinatal mortality as a proxy for socioeconomic status. To evaluate the perinatal mortality with a focus in risk areas, associated factors, avoidability causes and social inequalities, allowed better understanding of the magnitude of this local mortality and may contribute to prevention strategies.

Fêmeas Wistar foram alimentadas durante o período gestacional e a primeira metade da lactação (10 primeiros dias de lactação) com dieta normoprotéica (19 g proteína / Kg dieta) (grupo NP) e dieta restrita em proteínas (5 g proteína / Kg dieta) (grupo LP). Paralelamente a este esquema de alimentação, elas também receberam, diariamente, por gavagem, o óleo de peixe (Fo, rico em ácido graxo poliinsaturado- AGPi n-3). Os filhotes foram subdivididos em 4 grandes grupos: NP, NP-Fo, LP e LP-Fo, sendo acompanhados até os 6 meses de idade, data na qual ocorreu a eutanásia. No momento do sacrifício, o coração foi removido e devidamente preparado para a análise em microscopia de luz e estereologia. A partir do terceiro mês, os animais do grupo LP (ambos os gêneros) exibiram um aumento na pressão arterial sistólica (hipertensão moderada), mantendo esse comportamento até o final do experimento (6 meses de idade). No entanto, a suplementação materna com o Fo foi capaz de minimizar os efeitos da desnutrição sobre a pressão arterial. Não houve diferença significante no índice corporal entre os grupos de mães suplementadas com o Fo. O ventrículo esquerdo do grupo LP (ambos os sexos) demonstrou maior espessura quando comparado ao grupo NP (+25% nos machos, P=0,01, +22% nas fêmeas, P=0,001); entretanto, o grupo LP-Fo manifestou menor espessura quando comparado com o grupo LP (-23% nos machos, P=0,001, -12% nas fêmeas, P=0,02). Os machos do grupo LP apresentaram significativamente menor vascularização intramiocárdica quando correlacionado ao grupo NP (-50%, P=0,01), enquanto os machos do grupo LP-Fo exibiram um incremento de 89% na microcirculação, quando comparados ao grupo LP (P=0,004). Ambos os gêneros do grupo LP manifestaram maior quantidade de fibrose intersticial quando comparados ao grupo NP. Vale ressaltar que a suplementação materna de Fo foi benéfica apenas no grupo LP. Sendo assim, nossos dados sugerem claramente que a suplementação materna com Fo, durante o período perinatal, é capaz de prevenir o remodelamento cardíaco adverso e a hipertensão provocados pela restrição protéica materna in útero e na lactação, tornando-se assim uma opção não farmacológica viável para a prevenção e/ou redução dos danos ocasionados pela programação em humanos. / Female Wistar rats fed in gestation and first 10 lactation days with normal protein diet (19 g protein/kg diet) (NP group) or low-protein diet (5g protein/kg diet) (LP group), also received daily fish oil supplement (Fo, n-3 PUFA rich) during same period. Offspring put in groups NP, NP-Fo, LP, LP-Fo, until sacrifice at 6-mo-old when hearts removed, prepared for light microscopy and stereology. There was mild hypertension in both LP genders from 3- until 6 mo-old. Blood pressure affected by undernutrition was minimized by maternal Fo supplementation. In body index between groups there was no significant difference with maternal Fo supplementation. The left ventricle was thicker in both genders of LP groups compared to counterpart NP groups (+25% in male LP group, P=0.01, +22% in female LP group, P=0.001); however, less thick in LP-Fo groups compared to LP groups (-23% in male LP-Fo group, P=0.001, - 12% in female LP-Fo group, P=0.02). Male LP group offspring had significantly smaller intramyocardial microcirculation than NP group (-50%, P=0.01), while male LP-Fo group had 89% higher microcirculation than LP group (P=0.004). Both gender LP group offspring had significantly higher interstitial fibrosis compared with NP groups. The maternal Fo supplementation has beneficial effects in LP , but not in NP offspring. In conclusion, our data clearly indicate postnatal hypertension and collateral cardiovascular adverse remodeling, programmed by low-protein diet in utero and lactation was prevented by perinatal supplementation with fish oil, n-3 PUFA rich, providing a viable non-pharmacologic option for preventing and/or reducing adverse programming outcomes in human.

O presente trabalho procurou analisar a inserção da psicanálise nas novas formas de cuidado terapêutico em perinatologia, mais precisamente, no domínio que envolve os acontecimentos que ocorrem entre a concepção e os 36 meses de vida da criança. Para tanto, inicialmente foi apresentada a área da saúde materno-infantil no Brasil e as políticas públicas que a sustentam. Em seguida, delineou-se o funcionamento do campo escolhido, no caso uma maternidade de alto risco. Tendo em vista, a construção de uma rede de atenção tecida a partir de diferentes olhares, se procurou enfocar os impasses da interseção entre o discurso biomédico, o da educação em saúde e o da psicanálise. Nesse ponto, foi utilizada como referência principal a contribuição de D. W. Winnicott sobre a teoria do amadurecimento pessoal. Com a finalidade de circunscrever o crescente interesse pela primeira infância, procedeu-se a um mapeamento do estudo psicanalítico dos primórdios do psiquismo, após uma breve incursão pelo texto freudiano. Promoveu-se ainda uma discussão sobre o encontro das hipóteses psicanalíticas com as novas descobertas científicas sobre as potencialidades do bebê, ressaltando as consequências possíveis de tal intercâmbio. Por fim, foram destacadas algumas concepções que fundamentam a importância do olhar psicanalítico para o cuidado integral à saúde materno-infantil, enfatizando autores como Lebovici, Cramer, Bydlowski e Golse. Aqui as discussões teóricas entrelaçaram-se com observações de campo e vinhetas clínicas