Some maternal and child health issues in Chile

Dr. Francisco MardonesPublic Health Department

Faculty of MedicinePontifical Catholic University of Chile

(Pontificia Universidad Católica de Chile)

Population and birth statisticsLife Expectancy at Birth (in years)

Period Total Men Women

1919-22 31.54 30.90 32.31

1929-32 40.59 39.47 41.75

1939-42 41.83 40.65 43.06

1952-53 54.85 52.95 56.83

1960-61 57.07 54.35 59.90

1969-70 61.53 58.50 64.68

1980-85 70.70 67.37 74.16

1991-92 74.26 71.37 77.27

2001-02 77.36 74.42 80.41

Population and birth statistics

•Global situation: The highest values are from Japan (81.0), Monaco (80.5) and Andorra (80.4), while the lowest are found in Sierra Leona (37.9) and Malawi (37.8).

•Situation in Latin America: Chile (77.4), Costa Rica (77.3) and Cuba (76.7) have the highest values, while Bolivia (63.6) and Haiti (59.2) have the lowest ones.

Live births distribution according to place of delivery. Chile, 2005

Location of Birth Frequency Percentage

Hospital/Clinic 225568 97.72

House 164 0.07

Other 4717 2.04

Missing 382 0.17Total 230831 100

Live births information. Chile, 2005.Frequency Mean Standard

deviation Minimum Maximum

Weeks 230448 38.59 1.83 17 43

Weight 230448 3323.19 531.35 150 5870

Height 230331 49.37 2.72 16 63

Father's age 204055 30.70 7.78 14 85

Mother's age

230758 27.15 6.82 10 51

Present alive children

221597 1.98 1.11 0 22

Present death

children

221227 0.02 0.21 0 16

Stillbirths 221227 0.02 0.24 0 9

Total children

221597 2.02 1.18 0 23

Live births distribution according to birth weight. Chile, 2005

Birth weight (g) Frequency Percentage Cumulated percentage

<1000 1041 0.45 0.45

1001 - 1500 1290 0.56 1.01

1501 – 2000 2520 1.09 2.1

2001 - 2500 8273 3.59 5.69

2501 – 3000 38443 16.68 22.37

3001 – 3500 94027 40.8 63.17

3501 - 4000 67995 29.51 92.68

4001 – 4500 16103 6.99 99.67

4501 – 5000 729 0.32 99.99

> 5000 27 0.01 100.00

Total 230448 100 100.00

Live births distribution according to birth weight. Chile, 2005

0,45 0,56 1,09 3,5916,68

40,829,51

6,99 0,32 0,010

10

20

30

40

50%

Live births distribution according to length at birth. Chile, 2005

Length (cm) Frequency Percentage

<46 12134 5.27

46 –50 143415 62.26

51 – 53 69615 30.22

> 53 5167 2.25

Total 230331 100

Live births distribution according to sex. Chile, 2005.

Female48,65%

Male51,35%

Live births distribution according to weeks of gestation at delivery. Chile, 2005.

Gestation at delivery (weeks)

Frequency Percentage

<34 4402 1.91

<37 15852 4.96

Missing 383 0.17

Total 230831 100

Live births distribution according to mother´s level of education. Chile, 2005.

Completed Education Level

Frequency Percentage

Superior or University

50834 22.02

Secondary 134940 58.46Primary 44203 19.15

None 467 0.20Missing 387 0.17

Total 230444 100.00

Live births distribution according to mother´s employment. Chile, 2005.

Frequency Percentage

Non-active (domestic work)

158823 68.80

Owner of company 567 0.25

White collar worker 55974 24.25

Blue collar worker 9726 4.21

Independent worker

51960 2.25

Missing 545 0.24

Total 230831 100

Live births distribution according to father´s level of education. Chile, 2005.

Completed Education Level

Frequency Percentage

Superior or University

53917 23.36

Secondary 112669 48.81

Primary 37786 16.37

None 373 0.16

Missing 26086 11.30Total 230831 100.00

Live births distribution according to father´s employment. Chile, 2005.

Frequency Percentage

Non-active (retired or other)

11161 4.84

Owner of company 2730 1.18

White collar worker 87858 38.06

Blue collar worker 71256 30.87

Independent worker 27652 1198

Missing 30174 13.07

Total 230831 100

Live births distribution according to the presentation of single and multiple pregnancy.

Chile, 2005.Type of birth Frequency Percentage

Single 226313 98.04

Double 4038 1.75

Triple 92 0.04

Other 8 0.00

Missing 380 0.16

Total 230831 100.00

Live births distribution according to professional in charge at delivery. Chile, 2005.

Birth Attendant Frequency Percentage

Physician 85343 36.97

Midwife 145030 62.83

Without professional assistance

76 0,03

Missing 382 0.17

Total 238831 100

Components of the Infant Mortality Rate by Birth weight. Chile, 2005

Total Infant Mortality

RateEarly Neonatal Mortality rates

(< 7 days)

Neonatal Mortality rates

(<27 days)

Post-neonatal Mortality

rates

Infant Mortality

Rate

<=1000 461.10 515.85 28.82 544.67

1001-1500 74.42 96.90 13.95 110.85

1501-2000 28.17 38.49 13.49 51.98

2001-2500 10.03 12.57 7.13 19.70

2501-3000 2.60 3.38 2.00 5.38

3001-3500 0.64 1.11 1.30 2.40

3501-4000 0.81 1.12 1.06 2.18

4001-4500 0.68 0.87 0.68 1.55

4501-5000 0.00 1.37 1.37 2.74

Total 4.14 5.15 1.84 6.98

Mortality rates in children of ages 1 to 4, according to birth weight. Chile, 2005.

Birth weight (g)

Infant Mortality Rate

<=1000 1.09

1001-1500 0.65

1501-2000 0.67

2001-2500 0.51

2501-3000 0.22

3001-3500 0.20

3501-4000 0.17

4001-4500 0.19

4501-5000 0.43

>5000 0.00

Total 0.15

Mortality rates according to birth weight. Chile, 2005.

• Data on stillbirths is available, but it is not presented here.• Prevention of LBW babies in Chile. Recent proposals:

Improved food fortification during pregnancy. (Mardones F, Urrutia MT, Villarroel L, Rioseco A, Castillo O, Rozowski J, Tapia JL, Bastias G, Bacallao J, Rojas I. Effects of a dairy product fortified with multiple micronutrients and omega-3 fatty acids on birth weight and gestation duration in pregnant Chilean women. Public Health Nutr. 2008; 11 (1): 30-40. Improving neonatal care. (Mardones F, Marshall G, Viviani V, Villarroel L, Burkhalter BR, Tapia J-L, Cerda J, García-Huidobro T, Ralph C, Oyarzún E, Mardones-Restat F. Estimation of Individual Neonatal Survival Using Birthweight and Gestational Age: a Way to Improve Neonatal Care. J Health Popul Nutr 2008; 26 (1): 54-63.

How to improve neonatal care?

Mardones F, et al,. Estimation of Individual Neonatal Survival Using Birthweight and Gestational Age: a Way to Improve Neonatal Care. J Health Popul Nutr 2008; 26 (1): 54-63.

Population and birth statistics

• In Chile, the nutrition transition has taken place at a unique rate. In two decades undernutrition has practically disappeared, leaving instead high obesity figures in all age groups (Albala C et al. Public Health Nutr 2002;5:123-28).

• Obesity prevalence in the Chilean adult population was surveyed in year 2003 reaching 23.2% at the national level. Mardones F et al. Early Hum Dev 2007;83(Suppl 1):S162).

Population and birth statistics

• Chilean children attending first grade primary education in public schools have increased the obesity prevalence estimated with CDC standards from 17% in year 2001 to 19.4% in year 2006 (Ministry of Education. http://sistemas.junaeb.cl/estadosnutricionales_2007/index2.php).

Comparison of data from Chile with data from two provinces. 2003 & 2004

Chile Santiago (South East Health Service)

Arauco Province

Total births 244.486 20.611 2,649

Infant mortality ‰ LB *

7.8 6.4 15.2

Neonatal mortality ‰ LB *

4.9 4.9 11.3

Birth weight < 1501g (%) **

1 1 1.8

Birth weight <2501g (%) **

5.8 6.1 6.4

Birth weight <3001g (%) **

21.9 18.7 22.6

Pre-terms < 34 wks of gest (%) **

1.8 1.8 1.9

Pre-terms < 38 wks of gest (%) **

13. 8 9.5 15.1

**2003 *2004 Ministry of Health.

Nutritional deficits in poor areas: Pregnancy data in two provinces.

Variables South East Health Service of Santiago (n=333)

Arauco (n=383)

p

Calories (kcal) 2258.87 ± 598.96 1978.78 ± 893.26 0.000001

Proteins (g) 80.77± 23.59 65.30 ± 29.12 0.000000

Carbohydrates (g)

345.61± 98.71 302.23 ± 149.94 0.000004

Total fat (g) 64.45 ± 22.53 57.00 ± 31.41 0.000252

Omega-3 (g) ** Roughly

DHA 100 mg

0.57 ± 0.30 0.54 ± 0.57 0.370024

Omega-6 (g) 16.56 ± 6.88 12.58 ± 10.36 0.000000

Nutritional deficits in poor areas: Pregnancy data in two provinces.

Variables South East Health Service of Santiago

(n=333)

Arauco (n=383)

p

Vitamin A (mcg) 971.07 ± 1074.70 840.55 ± 1114.93 0.111626

Vitamin B1 (mg) 2.52 ± 0.78 2.38 ± 1.39 0.091679

Vitamin B2 (mg) 2.36 ± 0.77 1.93 ± 1.09 0.000000

Vitamin B6 (mg) 1.64 ± 0.66 1.65 ± 1.05 0.877221

Vitamin B12 (mcg) 4.54 ± 7.05 3.10 ± 6.33 0.004388

Vitamin C (mg) 116.38 ± 63.09 80.31 ± 76.99 0.000000

Vitamin D (mcg) 12.50 ± 7.73 5.96 ± 5.67 0.000000

Vitamin E (mg) 20.58 ± 8.71 12.84 ± 9.69 0.000000

Niacin (mg) 24.67 ± 7.35 22.17 ± 11.82 0.000607

Biotin (mcg) 19.27 ± 9.71 13.65 ± 9.13 0.000000

Folic acid (mcg) 580.02 ± 201.26 423.15 ± 233.96 0.000000

Nutritional deficits in poor areas: Pregnancy data in two provinces.

Variables South East Health Service of Santiago

(n=333)

Arauco (n=383)

p

Ca (mg) 924.83 ± 332.82 630.86 ± 381.72 0.000000

Mg (mg) 265.63 ± 85.75 206.24 ± 98.39 0.000000

Zn (mg) 10.58 ± 3.22 6.90 ± 3.46 0.000000

Fe (mg) 20.06 ± 8.03 19.60 ± 67.82 0.895273

Cu (mg) 1.78 ± 0.84 1.24 ± 0.72 0.000000

Se (mcg) 139.73 ± 46.98 120.10 ± 67.77 0.000006

Nutritional deficits in poor areas: Pregnancy data in two provinces.

Nutrients DRI Mean daily intake in Santiago(n=333)

Mean daily intake in Arauco (n=383)

% of DRI in Santiago

(n=333)

% of DRI in Arauco(n=383)

Vitamin A (mcg)

770 971 840 126.1 109.1

Vitamin C (mg)

85 116.4 80.3 136.9 94.5

Vitamin D (mcg)

5 12.5 6 250 119.2

Vitamin E (mg)

15 20.5 12.8 136.7 85.3

Nutritional deficits in poor areas: Pregnancy data in two provinces.

Nutrients DRI Mean daily intake in Santiago(n=333)

Mean daily intake in Arauco (n=383)

% of DRI in Santiago(n=333)

% of DRI in Arauco(n=383)

Vitamin B1

(mg), Thiamine1.4 2.5 2.4 178.6 171.4

Vitamin B2 (mg) Riboflavin

1.4 2.4 1.9 171.4 135.7

Niacin (mg) 18 24.7 22.2 137.2 123.3

Vitamin B6 (mg) 1.9 1.6 1.6 84.2 84.2

Folic acid (mcg) 600 580 423 96.7 70.5

Vitamin B12

(mcg)2.6 4.5 3.1 173.1 119.2

Biotin (mcg) 30 19.3 13.6 64.3 45.3

Nutritional deficits in poor areas: Pregnancy data in two provinces.

Nutrients DRI Mean daily intake in Santiago(n=333)

Mean daily intake in Arauco (n=383)

% of DRI in Santiago

(n=333)

% of DRI in Arauco(n=383)

Ca (mg) 1000 924.8 630.8 92.5 63.1

Cu (mg) 100 178 124 178 124

Fe (mg) 27 20 19.6 74.1 72.6

Mg (mg) 350 265.6 206.2 75.9 58.9

Phosphorus 700 1316.5 967.7 188.1 138.2

Se (mcg) 60 139.7 120.1 232.8 200.2

Zn (mg) 11 10.6 6.9 96.4 62.7

Pre-eclampsia in Chile• Preterm labor, low birth weight and

maternal preeclampsia are major causes of maternal and neonatal morbidity and mortality and are all interrelated (Rush 1976, Arias 1982, Van den Berg 1984, McIntire 1999, Donoso 1999 Donoso 2004, Lawn 2005, Bhutta 2005).

• Preeclampsia is the most frequent hospitalization diagnosis in obstetrics, and this has not changed significantly in the last decades (Oyarzun 1995, Neira 1997).

Pre-eclampsia in Chile• It is estimated that preeclampsia, including

chronic hypertension, affects around 10-12% pregnant women in Chile and universally (Neira 1997, Sibai 1998).

• Maternal hypertensive disorders are the most frequent cause of maternal mortality in Chile and are also associated with preterm delivery and with intrauterine growth restriction (Oyarzún 1995, Donoso 1999, Donoso 2004).

Pre-eclampsia in Chile• No effective therapeutic intervention has

been found to avoid or decrease the prevalence of this complication of pregnancy. We have recently reported an experiment showing a possible incidence reduction(Mardones et al 2008, to be shortly presented on Friday).

• Paliative measures, such as inhibition of uterine contractility, the use of bed rest, oxygen or antihypertensive drugs have not modified the prevalence or the course

Pre-eclampsia in Chile• In 515 pregnant women from the Arauco

province that included both primigravid and multiparae showed a 13.0% incidence of preeclampsia; 43% of these women had chronic hypertension. (Mardones F et al 2005).

• This preeclampsia incidence is substantially higher than the incidence observed in a survey from a big maternity hospital in Santiago, Chile: among 28,000 deliveries, preeclampsia was diagnosed in 8.5%, in both primiparae and multiparae women; 25% had chronic hypertension.

Maternal nutritional status in Chile• During the period of 1987-2001,

underweight pregnant women and birth weight < 3000 g decreased; these declines have been associated with better living conditions (Mardones F et al. Mat & Child Nutr 2005; 1 (2): 77-90).

• In 1987 the incidence of birth weight under 3000 g was 26.4%. A huge decline occurred between 1987 and 1990; after that it has been hovering around 20%.

• In fact, between 1990 and 2005 the proportion of BW < 3000 g is rather stable: 22.5% in year 2005.

Maternal nutritional status in Chile• On the other hand, Chile had a national

incidence of 6.05% for birth weight 4000 g in 1987 and 10.7% in 2001; nowadays is slightly over 9%. Over the same period of time the estimated proportion of obese pregnant women in the public health system has increased from 12.9% in 1987 to 32.6% in 2001.

• Pre-term deliveries < 37 w are slightly increasing.

Maternal nutritional status in Chile• Different studies have established that

anemia in the earliest stages of pregnancy is a public health issue in Chile. The most recent study done in Concepción province (Mardones F et al, ALAN, approved for publication, 2008) showed a prevalence of 14,5%, similar to a prevalence of 13,4% recently observed in Santiago (Mardones F et al. 2004).

• The prevalence of anemia in the province of Arauco and other poor areas has not been yet published. We are just finishing a study in Arauco province.

Descriptive Statistics of pregnant women delivering in the Sotero del Rio Hospital (Santiago,

S-E Health Area) 2001-2004.

N Minimum

Maximum

Mean Std. Deviation

Age 28852 12 48 26.27 7.11Pre-term delivery

28771 0 7 0.0674 0.30

Number of previous delivery

28401 0.00 12.00 1.0860 1.2138

Gestation 28335 0.00 13.00 1.3071 1.4441Height (cm) 28414 120 195 156.46 5.95

Maternal reproductive history

Hospital Sotero del Rio, Santiago 2001 2004.

Children Mean s.d.Alive 2.072 1.21Dead 0.022 0.16

Mortinate 0.010 0.12Total 2.104 1.25

Descriptive Statistics of pregnant women delivering in the Sotero del Rio Hospital (Santiago, S-E Health Area) 2001-2004.

N Minimum Maximum Mean Std. Deviation

Preconceptional weight (g)

27790 32 190 60.96 11.58

Weight at the end of

pregnancy (g)

27343 30 852 74.09 18.74

Initial BMI 27616 11.61 75.16 24.8833 4.4712

Final BMI 27086 11.87 341.31 30.2646 7.4039

Change in BMI 26499 -100.00 778.00 13.0517 16.1651

Gestational Age 28097 21 44 38.67 2.16

•We compared birthweight distributions from the same hospital. Healthy subjects were compared to the total sample.

•A recent technical report from the World Health Organization has proposed the development of birth weight references for each population based on observations of low-risk healthy pregnant women and their neonates (Promoting optimal fetal development. Geneva: WHO, 2006). We report a comparison of birth weight distributions from newborns delivered by pregnant women in Santiago, Chile.

• Women delivering single pregnancies at week 39-41, without pathologies or behaviors that may affect fetal growth were selected as healthy population (Mardones F et al. Early HD 2006; 82 (8): 512).

• A total of 28,897 newborns were studied. Healthy selected pregnancies resulted in 12,300 newborns. In the total sample mean birth weight was 3,314 ± 586 g, skewness -1.065, and kurtosis 3.299. In the healthy population mean birth weight was 3,505 ± 413 g, skewness 0.198 and kurtosis 0.705.

1000 2000 3000 4000 5000

pesog

0%

5%

10%

15%

20%

Peso al Nacer

Distribution of all newborns according to birth weight in Sótero del Río Hospital (Chile, 2000-2004).

1000 2000 3000 4000 5000

peso_n

0%

5%

10%

15%

20%

Peso al Nacer

Distribution of healthy term newborns according to birth weight in Sótero del Río Hospital (Chile, 2000-2004).

• A higher concentration of preterm births and specific maternal pathologies in the total population is interpreted as the cause for the observed skewness to the left in the birth weight distribution. Birth weight distribution of the healthy selected pregnancies was normal and it can be considered as an adequate standard for the population of newborns studied. Therefore this reference distribution might be an adequate target for health interventions

Body mass index (BMI) and gestional age: chart to

guide weight gain during pregnancy

(Mardones F, Rosso P. A weight gain chart for

pregnant women designed in Chile. Maternal and Child

Nutrition 2005; 1 (2): 77-90.

Pregnant women distribution according to Nutritional Status at the beginning of pregnancy.

Santiago, S-E Health Area, 2001-2004.

Birth weight (g)

n Mean S.D.

Red 2084 3363,0 371,5

Green 4978 3449,2 391,1 *Yellow 2791 3531,0 409,6 *

Orange 3928 3598,9 422,2 *

13,781 3495,4 409,4

Pregnant women distribution according to Nutritional Status at the beginning of pregnancy.

Santiago, S-E Health Area, 1983-1985.

Birth weight (g)

n Mean S.D.

Red 701 3314 384a

Green 596 3455 383bYellow 231 3531 385c

Orange 217 3614 386d

1,745 3428 398

Pregnant women distribution according to Nutritional Status at the end of pregnancy.

Santiago, S-E Health Area, 2001-2004.

Birth weight (g)

n Mean S.D.

Red 2749 3322,6 363,0

Green 3034 3423,9 365,3 *Yellow 1575 3500,9 390,7 *

Orange 6423 3601,8 419,9 *

13,781 3495,4 409,4

Pregnant women distribution according to Nutritional Status at the end of pregnancy.

Santiago, S-E Health Area, 1983-1985.

Birth weight (g)

n Mean S.D.

Red 663 3287 363a

Green 486 3450 398bYellow 198 3500 370b

Orange 398 3602 384c

1.745 3428 398

Mardones F et al. Association of perinatal factors and obesity in 6-8 years old

Chilean children. Int J Epidemiol 2008;37:902–10.

• 153,536 children entered the study. • Adjusted OR for perinatal information

showed that infants born male, premature and short in length at birth were more prone to obesity than their counterparts.

• However, birth weight had a stronger positive influence on obesity risk.

Mardones F et al. Association of perinatal factors and obesity in 6-8 years old Chilean children. Int J Epidemiol 2008;37:902–10.

• Taller and stunted children had higher obesity risk than normal height/age children.

• This association did not change when controlling for the influence of perinatal data; post-natal influences may be playing an independent role.

Relation of perinatal variables and height for age at 6-8 years to obesity risk

Crude univariate model Multivariate model

Variable Non-adjustedOR (95% CI)

AdjustedOR (95% CI)

SexMalesFemales

 10.79 (0.77–0.81)

 10.83 (0.80-0.85)

Birth length (cm)≤ 4647-49≥ 50

 11.11 (1.05–1.47)1.33 (1.26–1.40)

 10.91 (0.85-0.98)0.84 (0.78-0.91)

Gestational age at birth (weeks):≤ 37 38-42

  11.04 (0.99–1.08)

  10.83 (0.79-0.87)

Relation of perinatal variables and height for age at 6-8 years to obesity risk

Crude univariate model Multivariate model

Variable Non-adjustedOR (95% CI)

AdjustedOR (95% CI)

Birth weight (g)≤ 25002501-30003001-35003501-4000≥ 4001

 1 1.06 (0.99–1.14)1.26 (1-18–1.35)1.57 (1.46–1.68)2.03 (1.88–2.20)

 1 1.25 (1.14-1.31)1.60 (1.46-1.76)2.03 (1.84-2.24)2.59 (2.33-2.88)

Height for age at 6-8 years (percentiles)5-95< 5> 95

   11.20 (1.14–1.26)1.68 (1.59–1.76)

   11.27 (1.20-1.33)1.57 (1.49–1.65)