Recent Trends in Maternal, Newborn, and Child Health in Brazil: Progress Toward Millennium Development Goals 4 and 5

FRAMING HEALTH MATTERS
Recent Trends in Maternal, Newborn, and Child Health in

Brazil: Progress Toward Millennium Development Goals 4 and 5
o, MD,
Fernando C. Barros, MD, PhD, Alicia Matijasevich, MD, PhD, Jennifer Harris Requejo, PhD, MHS, Elsa Giugliani, MD, PhD, Ana Goretti Maranha
Carlos A. Monteiro, MD, PhD, Alusio J. D. Barros, MD, PhD, Flavia Bustreo, MD, MSc, Mario Merialdi, MD, PhD, MPH, and Cesar G. Victora, MD, PhD
We analyzed Brazils efforts in reducing child mortality, improving maternal

and child health, and reducing socioeconomic and regional inequalities from
1990 through 2007. We compiled and reanalyzed data from several sources,
including vital statistics and population-based surveys. We also explored
the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the
improvements observed. Our findings provide compelling evidence that proactive measures to reduce health disparities accompanied by socioeconomic
progress can result in measurable improvements in the health of children and
mothers in a relatively short interval. Our analysis of Brazils successes and
remaining challenges to reach and surpass Millennium Development Goals 4
and 5 can provide important lessons for other low- and middle-income
countries. (Am J Public Health. 2010;100:18771889. doi:10.2105/AJPH.2010.
196816)
The world is now well past the midpoint for the

achievement of the Millennium Development
Goals (MDGs), a set of internationally agreed
upon development aspirations to be achieved
by 2015. Maternal, newborn, and child health
are an integral part of these goals, yet global
progress toward MDG 4 (reducing child mortality) has been uneven, and MDG 5 (improving
maternal health) exhibits the least progress
worldwide of all health MGDs.13 The global
economic crisis is also negatively affecting the
most vulnerable women and children and
threatens to undermine efforts to reduce persisting inequities in service delivery and health
care outcomes.1,4 In this context, it is becoming
increasingly urgent to document and widely
disseminate country success stories in improving
maternal, newborn, and child survival so that
they may be replicated elsewhere.
Studies examining the success of low- and
middle-income countries in increasing coverage of essential maternal, newborn, and child
health services and narrowing the gaps between the richest and poorest population
groups have attributed these accomplishments
to health care reform measures and simultaneous improvements in womens access to education and income earning opportunities.58
These studies have shown that significant reductions in maternal, newborn, and child health
inequities can be achieved under diverse political
and economic conditions. Key to the success of
countries efforts to progress toward MDGs 4 and
5 have been political commitment to universal
access to services across the continuum of care9
and the adoption of specific measures (e.g.,
implementation of a coherent mix of financial
protection schemes) aimed at ensuring that no
population groups are excluded.10,11
Brazil, the nation with the largest economy
in Latin America and a country historically
characterized by substantial health and wealth
inequities, has made rapid strides in improving
maternal, newborn, and child health. In 2005,
because of its high absolute number of child
deaths, Brazil was included among the 60
priority countries (i.e., countries accountable
for 94% of all child mortality) in the countdown to the 2015 deadline for achieving all
MDGs.12 The latest estimates show, however,
that Brazil is on track for MDG 4 and is making
good progress in increasing coverage for interventions relevant to MDG 5.13 Also, Brazil is
unique among low- and middle-income countries
because of its tax-based unified health service,
introduced in 1988, that offers free and
October 2010, Vol 100, No. 10 | American Journal of Public Health
comprehensive health care to all Brazilian citizens regardless of employment status or contributions to Social Security.
Brazil has 1 federal district (Brasilia) and 26
states (we refer to 27 states throughout for the
sake of simplicity) divided into 5 regions:
North, Northeast, Southeast, South, and West
Central. The Southeast and South regions are
the most developed; the North and Northeast
regions are the poorest. The North region,
dominated by the Amazon area, is the largest,
with 45.2% of the land area, but it comprises
only 8.1% of the population. The WestCentral
region has the second largest area, but the
population corresponds to only 7.1% of the
country. Most of the population is concentrated
in the Southeast (42%), and an additional
14.5% of the countrys residents live in the
South, which has a subtropical climate. The
Northeast region has a population of nearly 54
million, corresponding to 28.2% of the countrys residents.14
Our goals were to investigate trends in
maternal, neonatal, infant, and child mortality
in Brazil from 1990 to 2007 and interpret
these trends in the light of health sector reforms, the introduction of pro-poor policies and
programs, and broad socioeconomic and demographic changes. To determine whether and
how inequities in these mortality indices
changed, we examined trends in child and
infant mortality across wealth quintiles and
regions. We also documented changes in the
cause distribution of infant deaths nationally
and by region and examined available maternal mortality estimates from 1990 to 2006.
To identify possible reasons for the downward mortality trends and improvements in
mortality differentials among children younger
than 5 years, we assessed broad health sector
changes, the introduction of specific programs
and policies targeted at women and children, and
coverage trends associated with proven
Barros et al. | Peer Reviewed | Framing Health Matters | 1877
maternal, newborn, and child health interventions during the study period. Changes in key
socioeconomic, child nutritional status, and
demographic factors known to influence maternal, newborn, and child health outcomes
were also reviewed.
METHODS
We compiled and reanalyzed data from
several different sources, including vital statistics and population-based surveys, to assess
neonatal, infant, and child mortality; maternal
mortality; intervention coverage; and trends in
nutrition.
Neonatal, Infant, and Child Mortality

Data on neonatal (027 days), postneonatal
(28364 days), infant (0364 days), and child
(1259 months) mortality, as well as mortality among infants and children aged younger
than 5 years (059 months), were obtained
from several sources. Methods for the calculation of these mortality rates are not uniform
across the country.
In the case of 8 states (all from the Southeast,
South, and WestCentral regions) where vital
statistics are considered reliable according to
a set of criteria developed by the Inter-Agency
Network for Health Information,15 mortality
was estimated by dividing the number of registered deaths (obtained from the System of
Mortality Information; available at http://
www.datasus.gov.br/catalogo/sim.htm) by the
number of live births (obtained from the Live
Births Information System; available at http://
www.datasus.gov.br/catalogo/sinasc.htm). For
the remaining 19 states, indirect mortality estimates from national censuses and household
surveys were used. Data for the country as
a whole were obtained through state-level estimates weighted by the number of live births.15
Vital statistics information was used to calculate the proportions of infant deaths due to
different causes defined according to codes
from the International Classification of Diseases
(ICD-916 from 1990 to 1995 and ICD-1017
thereafter). ICD-9 codes were categorized as
follows: perinatal (760779), malformations
(740759), respiratory infectious diseases
(460466, 480487), diarrhea (001009),
other infections (010139, 320322, 390
398), and ill-defined causes (780799). The
following ICD-10 categories were used: perinatal

(P00P96), malformations (Q00Q99), respiratory infectious diseases (J10J18, J20J22), diarrhea (A00A09), other infections (A15A99,
B00B99, G00G09), and ill-defined causes
(R00R99).
Because underregistration may be more
common at certain ages (e.g., for young infants) or as a result of certain causes (e.g.,
diarrhea and other poverty-related diseases),
proportionate mortality ratios may also be
distorted, but probably to a lesser extent than
are population-based rates derived from official statistics. Deaths due to ill-defined causes
(including those not involving medical assistance and those attributed to nonspecific signs
and symptoms) were excluded from the proportionate mortality analyses and are
reported separately. We multiplied the overall infant mortality rate by cause-specific
proportions of deaths to obtain mortality rates
by cause.
We calculated mortality rates among infants
and children aged younger than 5 years
(hereafter under-5 mortality rates) for 1996
and 2006 using a direct estimation method
based on KaplanMeier survival analyses,
which were performed through the ST set of
commands in Stata version 11.0 (StataCorp LP,
College Station, TX). Self-reported maternal
birth histories, collected in Brazilian national
surveys (the 1996 Demographic and Health
Survey and a similar survey carried out by the
Ministry of Health in 20062007, referred to
as PNDS 2006 [Pesquisa Nacional sobre
Demografia e Saude]; hereafter the 1996 and
20062007 national surveys), were used for
these calculations. Sample weights were incorporated in the analyses, but the Stata procedure
does not allow clustering to be taken into
account. Trend data on preterm births were
obtained from a recently conducted systematic
review of the literature.18
Two additional issues are associated with

estimating maternal mortality rates. First, maternal causes are often underreported, even
among registered deaths. A mortality survey
conducted among reproductive-age women in
25 Brazilian states in 200221 estimated that the
reported number of maternal deaths should be
multiplied by 1.4 to account for misreporting of
causes of death. This correction factor is similar
to international recommendations.22 The second
issue is that maternal mortality audits have been
implemented widely throughout the country in
recent years, and these audits are known to
increase reporting of maternal deaths. For these
reasons, estimates of levels of and trends in
maternal mortality in Brazil must be interpreted
with great caution.
We also analyzed maternal mortality by
cause, using data on registered deaths reported
to the Ministry of Health during 2007, the
latest available year. Causes were categorized
according to the following ICD-10 codes: hypertensive disorders of pregnancy (O10O16),
sepsis or infection (A34, O23, O85, O86),
hemorrhage (O20, O46, O72), abortion (O00
O03, O05O07), placental disorders (O43
O45), other complications of labor (O75),
embolism (O88), abnormal uterine contractions (O62), HIV/AIDS (B20B22, B24), other
direct causes (D39, F53, O21, O22, O24, O26;
O29O31, O33, O36, O40O42, O47, O60,
O63, O65, O67O69, O71, O73, O74, O87,
O89, O90, O95), and other indirect causes
(O98, O99).
Intervention Coverage
Information on the coverage of key maternal
and child health interventions was obtained
from the 1996 and 20062007 national
surveys.23,24 Data on vaccination coverage were
not collected in the 20062007 survey, and we
relied instead on governmental figures derived
from routine reporting. Key interventions were
defined as follows:
Maternal Mortality
Unlike child mortality, census- and surveybased estimates of maternal mortality do not
provide information for the immediate past
because the data collected refer 10 to 12 years
before the survey.19 Vital statistics are thus the
only source of information available, but, as
mentioned, these data are reliable for only 8 of
the countrys states.20
1878 | Framing Health Matters | Peer Reviewed | Barros et al.
1. Piped water: proportion of households with

piped water in the dwelling or plot;
2. Prevalence of contraceptive use: percentage
of married or in-union women aged 15 to
49 years currently using any modern means
of contraception;
3. Antenatal care: percentage of pregnancies in
the 5 years prior to the survey in which the
American Journal of Public Health | October 2010, Vol 100, No. 10
4.
5.
6.
7.
8.
9.
mother received at least 4 antenatal care

consultations from a medically trained person;
Delivery attendance by a medically trained
person: percentage of births in the 5 years
prior to the survey attended by a medically
trained person;
Cesarean delivery: percentage of births by
cesarean delivery;
Diphtheria, pertussis, and tetanus (DPT)
vaccination: in 1996, the percentage of
children aged 12 to 23 months who had
received 3 or more doses of DPT according
to the Demographic and Health Survey, and,
in 2007, the percentage of children in this
age range who had received 3 or more doses
of tetravalent (DPT plus Haemophilus
influenzae) vaccine;
Measles vaccination: in 1996, the percentage of children aged 12 to 23 months who
had received 1 or more doses of the vaccine,
and, in 2007, the percentage of children in
this age range who had received 1 or more
doses of triple viral (measles, mumps, and
rubella) vaccine;
Care seeking for suspected pneumonia:
percentage of children with a cough and
rapid breathing in the 2 weeks prior to the
survey who had been taken for treatment to
any medical facility or provider, whether
public or private;
Use of oral rehydration solution: percentage
of children with diarrhea in the 2 weeks
prior to the survey who had received oral
rehydration salts, commercial preparations,
or a homemade (salt and sugar) solution.
Nutrition
The World Health Organizations child
growth standards25 were used to assess the
nutritional status of children aged younger than

5 years participating in the 1996 and 2006
2007 national surveys, as well as the status of
mothers and children who took part in a nationwide evaluation conducted in 1989.26 Prevalence of stunting (height-for-age), prevalence of
underweight (weight-for-age), and prevalence of
wasting (weight-for-height) were defined according to the percentage of children with Z scores
for each indicator below 2 SDs of the median
reference standard for their age, whereas overweight was defined as the percentage of children
with more than 2 Z scores of height-for-height for
their age.
We estimated breastfeeding duration using
the current status method, in which mothers
were asked if they were currently breastfeeding
their babies.27 Prevalence of exclusive breastfeeding was defined according to the percentage
of children who had received only breast milk in
the 24 hours prior to the survey.
Data Analyses
The data sets from the 1996 and 2006
2007 national surveys were reanalyzed to
produce estimates of intervention coverage
and under-5 mortality by socioeconomic
groups defined on the basis of principal-component analyses of household assets.28 We
opted to use this widely employed method of
characterizing socioeconomic position to allow
international comparisons.
We also present results from the concentration index, which compares the distribution of
a specific variable or outcome between different socioeconomic group strata.29,30 This index
ranges from 1 to 1, with a value of 0 indicating
complete equality. If the variable reflects morbidity or mortality, the concentration index is
usually negative, meaning that ill health is more

frequent among the poor. The concentration
index is usually positive for coverage indicators,
which tend to be higher among the rich.30 Slope
indices of inequality were also calculated to
express trends in coverage across the 5 quintiles
designated in this study (quintile 1 comprised the
poorest population groups and quintile 5 the
richest groups).31
RESULTS
This section includes information on mortality among children and mothers, as well as
trends in childrens nutritional status, breastfeeding, health interventions, and socioeconomic inequalities.
Neonatal, Infant, and Child Mortality

Figure 1 shows the declines in Brazilian neonatal and infant mortality rates between 1990
and 2007. Infant mortality dropped from 47.1
per 1000 live births in 1990 to 20.0 in 2007, an
average yearly decline of 5.1%. The decline
was slightly faster in the 1990s (5.5% per year)
than it was after 2000 (4.4% per year).
Neonatal mortality rates also showed an
important decrease in the period, from 23.1 per
1000 live births in1990 to 13.6 in 2007 (Figure
1). The average yearly decline was 3.2%, less
marked than the overall decline in infant deaths.
By contrast, postneonatal mortality dropped
from 24.0 to 6.4 per 1000 live births, an 8.1%
yearly decline. As a consequence of the lower
rate of decline in neonatal mortality, the relative
contribution of this component to infant mortality increased from 49% to 68%.
According to data from the 1996 and
20062007 national surveys, mortality rates
FIGURE 1Trends in infant, neonatal, and postneonatal mortality rates: Brazil, 19902007.
FIGURE 2Trends in infant mortality rates, by region: Brazil, 19902007.
among children aged 1 to 4 years were considerably lower than were infant mortality
rates, declining from about 6 deaths per 1000
live births in the early 1990s to 3 per 1000
live births after the year 2000. In addition, the
under-5 mortality rate fell from 53.7 per
1000 live births in 1990 to 23.1 per 1000 live
births in 2007, an overall reduction of 57.0%,
which corresponded to an average annual
rate of reduction of 4.8%.
There were declines in infant mortality from
1990 to 2007 in all Brazilian regions (Figure
2), with the most marked changes in the
Northeast, where the yearly decrease reached

5.9% (75.8 per 1000 live births in 1990 to 28.7
per 1000 live births in 2007). Declines in the
North (4.3% per year), Southeast (4.9% per
year), South (4.5% per year), and WestCentral
(4.1% per year) regions were also substantial.
In 1990, the infant mortality rate in the
region with the highest mortality (the Northeast) was 2.6 times greater than was that in the
region with the lowest mortality (the South). By
2007, this ratio had been reduced to 2.2.
There were 47.1 additional deaths per 1000
live births in the Northeast than in the South in
1990, but this excess had fallen to 15.3 deaths

per 1000 live births in 2007. Despite such
progress, the infant mortality rate in the
Northeast region in 2007 (28.3 per 1000 live
births) was essentially the same as that in the
South 17 years earlier (28.7 per 1000 live
births).
There were important variations in the rates
of decline for different causes of death from
1990 to 2007 (Figure 3). The most marked
decline was in diarrhea mortality (a decline of
92.4%, from 6.6 to 0.5 per 1000 live births),
followed by respiratory infections (decline of
FIGURE 3Trends in cause-specific infant mortality rates: Brazil, 19902007.
81.8%) and other infectious diseases (decline of

69.2%). Diarrhea deaths fell markedly in all
regions, including the Northeast, where the
rates were highest in 1990.
Deaths due to perinatal causes fell by 47.0%,
but deaths due to malformations remained
almost constant, with a 7.7% reduction over the
17-year period. Deaths due to ill-defined causes
were proportionately allocated to these 2 categories; in 1990 there were 9.0 such deaths per
1000 live births, whereas by 2007 this rate had
decreased to 0.8 per 1000 live births.
Table 1 shows cause-specific infant mortality
rates by cause and region of the country for the
1990 through 1994, 1995 through 1999,
2000 through 2004, and 2005 through 2007
periods. The trends observed for the country as
a whole (Figure 3) were also present in every
region, with generally similar magnitudes of
reduction. The only exception involved deaths
due to congenital malformations, which increased in the North and Northeast, remained
stable in the WestCentral, and dropped in the
South and Southeast. This was probably due
to improved ascertainment of such deaths in
the least developed areas of the country in
recent years.
TABLE 1Cause-Specific Infant Mortality Rates: Brazil, 19902007

Region
Cause and Period
North, %
Northeast, %
Southeast, %
South, %
WestCentral, %
Total, %
19901994
21.4
31.0
15.8
12.6
16.3
21.7
19951999
20.2
27.2
13.7
10.0
13.8
18.4
20002004
17.1
23.3
9.9
9.3
11.5
15.0
20052007
Malformations
13.6
18.6
9.0
7.9
9.9
12.6
19901994
2.8
3.6
3.0
3.6
3.4
3.9
19951999
2.9
3.7
2.9
3.1
3.4
3.7
20002004
3.0
3.7
2.7
3.2
3.6
3.5
20052007
3.2
4.1
2.8
3.1
3.5
3.5
19901994
4.5
7.6
4.0
3.5
3.5
5.4
19951999
20002004
2.3
1.7
3.8
1.8
1.9
0.9
1.6
0.8
1.6
0.9
2.5
1.3
20052007
1.4
1.5
0.7
0.4
0.8
1.0
19901994
7.5
14.9
2.1
2.3
3.1
5.2
19951999
2.8
7.6
1.0
0.9
1.4
2.5
20002004
1.4
2.9
0.4
0.4
0.7
1.1
20052007
1.0
1.7
0.2
0.2
0.5
0.7
Perinatal
Respiratory infections
Diarrhea
Other infections
19901994
2.3
4.6
1.6
1.4
2.0
2.5
19951999
1.8
3.0
1.3
0.9
1.4
1.8
Maternal Mortality
20002004
1.3
1.7
0.7
0.6
0.8
1.1
As mentioned, recent data on maternal

mortality rates and trends are limited. Since
1980, a number of different methods have
been used to calculate maternal mortality, and
the resulting estimates have varied widely
(Table 2).15,19,21,3237 These estimates are affected simultaneously by underregistration of
deaths in general, underreporting of maternal
causes among registered deaths, and improved
detection of maternal deaths as a consequence of
audit procedures. In several Brazilian studies,
a correction factor (usually 1.421) has been
applied to take into account underreporting of
maternal causes; few studies have also taken
general underregistration of deaths into account.36
Recent (post 2001) estimates based on vital
statistics are available for 8 of the 27 states
where death registration coverage is regarded
as reliable (Table 2).15 The average rate from
these states, weighted by the annual number of
births, ranged from 70.9 to 77.2 per 100000
live births between 2001 and 2006, without any
clear time trends. In these estimates, a fixed
20052007
1.3
1.2
0.6
0.4
0.6
0.8
19901994
9.7
25.7
1.7
2.2
2.6
7.8
19951999
5.0
12.2
1.2
1.2
1.4
3.9
20002004
20052007
3.4
1.9
5.8
1.4
0.8
0.6
0.7
0.5
0.6
0.5
2.3
1.0
19901994
41.4
67.3
29.1
25.8
31.1
42.5
19951999
32.5
50.3
23.0
18.6
23.9
32.0
20002004
26.6
37.1
17.6
16.0
19.6
25.0
20052007
22.8
29.9
15.0
13.4
17.1
20.7
Ill-defined causes
All causes
correction factor of 1.4 was applied to allow for

underreporting of maternal deaths among registered deaths. The 8 states on which these
estimates are based are all in the South and
Southeast regions; maternal mortality in these
states, which are the richest in the country
and have the strongest health services infrastructure, is likely to be lower than in the other
states.
Table 3 shows the reported causes of registered maternal deaths during 2007 for each
region. Overall, the leading causes of death were
hypertensive disorders of pregnancy,
responsible for 22.6% of all deaths, followed by
sepsis and hemorrhage. Abortion deaths were
the next most frequent cause, but underreporting
of such deaths appears to be severe38 given that
induced abortions are illegal in almost all cases.
TABLE 2Maternal Mortality Ratio Estimates From Different Data Sources: Brazil, 19902006
Maternal Mortality Ratioa
Source (Years of Estimate)
Comments on Methodology
1996 Demographic and Health Survey23 (19831996)
161
Based on direct sisterhood method (all interviewed adults are asked about the death of a sister
UNICEF/WHO32 (1990)
220
Based on projection model using as independent variables the general fertility rate and the
Pan American Health Organization35 (1991)
114
Methodology not described.
as a result of a possible maternal cause).

proportion of births assisted by a trained person.
Ministry of Health33 (1995)
Ministry of Health34 (1996)
44
39
Victora36 (19951997)
147
Based on registered deaths, uncorrected.

Based on hospital deliveries (hospital information system), uncorrected.
Based on registered deaths, corrected for overall underregistration plus underreporting of
maternal causes.
Laurenti et al.21 (2002)
54.3
Based on reproductive-age mortality survey methodology, using a factor of 1.4 to correct for
underreporting of maternal causes among registered deaths; study covered all 27 capitals.
RIPSA15 (adopted by the Ministry of Health)

2001
70.9
Average maternal mortality ratio calculated for 8 states where vital registration meets criteria
2002
2003
75.9
73.0
for reliability (RIPSA); a factor of 1.4 was applied to correct for underreporting of maternal
deaths; the denominator was the number of live births.
2004
76.1
2005
74.7
2006
77.2
WHO, UNICEF, United Nations Population Fund, World Bank37 (2005)
110
Based on the RIPSA estimate of 74 per 1000 for 2005, multiplied by a correction factor of 1.5;
this correction was applied arbitrarily to all countries, with estimates based on reproductiveage mortality surveys.
Note. RIPSA = Rede Inter-Agencial de Informac

xoes para a Saude [Inter-Agency Network for Health Information]; UNICEF = United Nations Childrens Fund; WHO = World Health Organization.
a
Ratio per 100 000 births.
Placental disorders, other complications

of labor, embolism, and abnormal uterine
contractions each also cause a significant share
of maternal deaths. HIV/AIDS was responsible
for 3.9% of registered deaths and was proportionally more important in the South and
Southeast regions. Other indirect obstetric
causes (preexisting diseases complicated by
pregnancy) accounted for nearly 17% of
reported deaths. Information on registered
deaths must be interpreted with caution as
a result of differences in underregistration
among regions and the fact that maternal
mortality audit committees are more active in
some states than in others.
Trends in Nutritional Status and

Breastfeeding
Table 4 shows the prevalence of stunting,
underweight, wasting, and overweight among
children aged younger than 5 years in national
surveys conducted in 1989, 1996, and 2006
2007. A clear decline in stunting prevalence
can be observed, with a decrease from 19.9%

in the first survey to 7.1% in 20062007. The
estimates show that underweight prevalence
declined to 2.2%, the level expected according
to the World Health Organization growth
standard distribution based on healthy and
well-nourished children. Wasting prevalence
had already reached in 1989 the prevalence
expected for a well-nourished population
according to the WHO growth standards. On
the other extreme of the nutritional spectrum,
the prevalence of overweight did not change
significantly and remained at approximately
7% to 8% in the 3 surveys.39
Data on recent trends in breastfeeding are
available from 2 sources. Interviews of probability samples of mothers who accompanied
their children to national immunization days in
1999 and 2008 were conducted in the 27
state capitals.40 Because attendance at national
immunization days is close to 100%, these
studies provide precise information on health
behaviors. The point prevalence of exclusive
breastfeeding among infants aged zero to 4

months increased from 35.5% in 1999 to 51.2%
in 2008. Approximately 42% of infants aged 9
to 12 months received any breast milk in 1999,
as compared with 58.7% in 2008. The median
duration of any breastfeeding increased from
10.0 to 11.2 months from 1999 to 2008.
The 1989, 1996, and 20062007 national
surveys were the second source of breastfeeding data; these surveys (in which the current
status methodology27 was used) also showed an
increase in the median duration of any breastfeeding, from 2.5 months in 1974 to 5.5 months
in 1989, 7.0 months in 1996, and 14.0 months in
20062007.23,24,41 These trends reflect longterm improvements in breastfeeding. We analyzed exclusive breastfeeding among infants aged
zero to 3 months in the 20062007 survey and
found a prevalence of 64.3% for the population
as a whole. Reliable data from the 1996 survey
are not available.
Results from these 2 sources are not strictly
comparable because the national immunization
TABLE 3Causes of Maternal Mortality, by Region: Brazil, 2007

Region
Cause Group
North, %
Northeast, %
Southeast, %
South, %
WestCentral, %
Total, %
Hypertensive disorders of pregnancy
21.3
26.7
22.4
14.6
19.6
22.6
Sepsis
12.9
6.6
11.5
10.4
10.3
9.7
7.9
7.2
7.8
8.9
8.2
7.7
Hemorrhage
Abortion
9.4
7.0
10.0
7.3
7.2
8.4
Placental disorders
Other complications of labor
4.0
4.0
4.3
4.7
5.9
3.7
5.7
1.6
5.2
5.2
5.0
3.9
the information is difficult to interpret owing

to the small number of children with reported
diarrhea episodes in the 2 weeks preceding the
surveys. As for pneumonia, the apparently low
coverage must be interpreted in light of the
virtual eradication of diarrhea deaths.
A remarkable characteristic of delivery care
in Brazil is the high proportion of cesarean
deliveries. The percentage of such deliveries
increased from 36% in 1996 to 44% in 2006
2007.
Embolism
3.5
4.8
3.0
3.6
6.2
4.0
Abnormal uterine contractions
5.4
3.9
5.0
1.6
6.2
4.3
Trends in Socioeconomic Inequalities
HIV/AIDS
2.5
1.8
5.7
7.3
2.1
3.9
18.8
14.0
11.9
15.1
10.3
13.8
Data from nationally representative surveys

were reanalyzed to assess time trends in socioeconomic disparities in under-5 mortality,
stunting prevalence, and intervention coverage.
Figure 5 shows under-5 mortality rates based
on the 1996 and 20062007 national surveys, stratified by family asset quintiles. To
ensure sufficient sample sizes in each quintile, it
was necessary to base the estimates on births
and deaths occurring in the 10 years prior to
each survey. Thus, estimates based on the
1996 survey refer to the period 1987 through
1996 (midpoint 1991), and the midpoint for
estimates from the 20062007 survey was
20012002.
Important declines in mortality can be seen
in all quintiles. The most marked decline in
absolute terms was observed in the poorest
quintile, from 96 to 39 deaths per 1000
population. The difference between the richest
and poorest quintiles fell from 65 deaths per
thousand in 1991 to 31 deaths per thousand in
20012002. Likewise, the slope index of
inequalitywhich can be interpreted as the
difference in mortality rates between the top
and bottom of the socioeconomic scalefell
from 78 to 38 deaths per 1000. In relative
terms, however, inequality increased. The
quintile 1 to quintile 5 ratio of 3.1 in 1991
increased to 4.9 in 20012002. The quintile 1
to quintile 5 ratio in 20012002 may have
been influenced by the very low mortality in
the richest quintile in 20012002, but the
concentration indexwhich also expresses relative inequalityshowed a similar increase
from 0.261 to 0.295 in the same period.
A recent Brazilian study analyzed national
surveys to examine time trends in socioeconomic inequalities in child stunting.39 In 1989,
39.1% of children from families in the lowest
Other direct causes

Other indirect causes
Total
10.4
19.1
13.1
24.0
19.6
16.6
100.0
100.0
100.0
100.0
100.0
100.0
Note. Reported percentages may not total 100 because of rounding.
day surveys were restricted to state capitals

and the household surveys were conducted
across the country. However, both sets of data
point out to important increases in breastfeeding duration.
Trends in Intervention Coverage

Figure 4 shows changes in the coverage of
key maternal and child health interventions in
the 1996 and 20062007 national surveys
(with the exception of vaccine coverage data,
which were not collected in 20062007 but
were derived from the countrys health information system). Baseline levels were already
quite high in the earlier survey for most interventions, and, with the exception of oral
rehydration, all other indicators showed
increases in the decade. The only indicator

from 20062007 with coverage below 50%
was medical attention for suspected pneumonia (children with cough along with rapid or
difficult breathing); this finding, however, was
not consistent with the relatively low mortality
due to respiratory infections (Table 1) and
raises the possibility of measurement problems.
Information on the commonly used indicator for oral rehydration therapy (use of oral
rehydration salts, other recommended home
fluids, or other increased liquids) was not
available in the 20062007 survey. It was
possible, however, to compare the proportions
of children who received oral rehydration
solutions. There was no evidence of an increase
in overall coverage between the 2 surveys, but
TABLE 4Prevalence of Underweight, Stunting, Wasting, and Overweight Among Children

Assessed in 3 Brazilian National Surveys: 19892007
Stunting,a %
(95% CI)
Underweight,b %
(95% CI)
Wasting,c %
(95% CI)
Overweight,d %
(95% CI)
1989 (n = 7374)
19.9 (17.8, 21.9)
5.6 (4.9, 6.4)
2.2 (1.6, 2.8)
8.4 (7.4, 9.4)
1996 (n = 4149)
13.5 (12.1, 14.8)
4.6 (3.9, 5.4)
2.5 (1.9, 3.0)
7.4 (6.5, 8.4)
7.1 (5.7, 8.5)
2.2 (1.5, 2.8)
1.6 (0.9, 2.2)
7.3 (6.1, 8.5)
Survey Year
20062007 (n = 4414)
Note. CI = confidence interval.
a
Height for age < 2 SDs.
b
Weight for age < 2 SDs.
c
Weight for height < +2 SDs.
d
Weight for height > +2 SDs
Note. ARI = acute respiratory infection; DPT = diphtheriapertussistetanus. Data are from the 1996 Demographic and Health
Survey23 and a similar survey (Pesquisa Nacional sobre Demografia e Saude) carried out by the Ministry of Health in 2006
2007.24
FIGURE 4Time trends in selected coverage indicators, by survey year: Brazil, 19962007.
income quintile were stunted, as compared with

5.1% in the top quintile. By 20062007, these
prevalence rates had declined to 11.2% and
3.3%. The poorrich gap in stunting declined
from 34 percentage points in 1989 to 7.9
percentage points in 20062007, and the poor
rich prevalence ratio fell from 7.7 to 3.4. The
slope index of inequality fell from 46.1 to 9.7
percentage points, and the concentration index decreased from 0.34 to 0.16.39 Therefore, inequality fell in both absolute and relative
terms.
We analyzed socioeconomic gradients in
exclusive breastfeeding among infants aged 3
months in the 20062007 national survey.
Prevalence rates for each group of asset quintiles, from the poorest to the richest, were as
follows: 59.4%, 59.7%, 65.7%, 65.8%, and
77.9%.
Table 5 shows the coverage of selected
indicators, by quintiles of family assets, analyzed in the 1996 and 20062007 national
surveys. For each variable, the ratio and the
difference between the poorest and the richest
quintiles are presented, as well as concentration and slope indices. A common pattern of
reduced absolute and relative inequities in the
study period can be seen, with antenatal care
and skilled attendance at delivery becoming
nearly universal in all socioeconomic groups in
the 20062007 survey and virtually all births
now taking place in a hospital. The main
exception is oral rehydration fluids, for which
coverage was highest in the third quintile in
both surveys; these findings must be
interpreted with caution given the small number of children from wealthy families who
presented with diarrhea.
DISCUSSION
Our examination of trends in child, infant,
neonatal, postneonatal, and under-5 mortality
in Brazil between 1990 and 2007 showed
declines across all 5 indices, with the greatest
annual rate of reduction occurring during the
postneonatal period followed by improvements
in the infant mortality rate. The neonatal
mortality rate improved the least, a finding

consistent with other research showing that, in
countries undergoing transition, this rate is
slower to improve than are infant and child
mortality rates.42 If Brazil is to reach MDG 4, the
country must achieve an annual reduction of
4.1% in its under-5 mortality rate. Our findings
show that the under-5 mortality rate dropped
4.8% per year during the study interval, putting
Brazil well on track to achieve MDG 4 by 2011.
We found substantial declines in the infant
mortality rate in all regions, with the greatest
proportional decrease occurring in the Northeast, the highest mortality region in the country. The observed narrowing of the infant
mortality gap between the Northeast and South
regions of the country is an indication of
Brazils success in reducing regional inequities.
Data on trends in socioeconomic inequalities suggest that overall progress in maternal
and child health indicators in Brazil was accompanied by a marked reduction in the
poorrich gap in stunting and intervention
coverage, in both absolute and relative terms.
The picture for under-5 mortality is
somewhat different; the absolute gap decreased markedly from 1991 to 20012002,
but the relative gap increased. Information
disaggregated by wealth is not available after
20012002, as these estimates refer to the 10
years prior to the survey; as a consequence,
Note. Data are shown from the 1996 Demographic and Health Survey23 and a similar survey (Pesquisa Nacional sobre
Demografia e Saude) carried out by the Ministry of Health in 20062007.24 Both surveys refer to the 10 years prior to the
survey administration. Thus, estimates based on the 1996 survey refer to the period 1987 through 1996 and have a midpoint
at 1991, and estimates based on the 20062007 have at midpoint at 20012002. Estimates were calculated by the authors.
FIGURE 5Mortality rates among Brazilian infants and children aged younger than 5 years,
by survey year and wealth quintile: Brazil, 19962007.
TABLE 5Time Trends in Coverage of Selected Indicators of Maternal and Child Health Interventions, by Wealth Quintile and Inequality
Indicator: 1996 and 20062007 Brazilian National Surveys
Wealth Quintile
Indicator and Year of Survey
Ratioa
Differenceb
Concentration
Index
Slope Index
of Inequality
Skilled birth attendance

1996
72.6
89.8
96.8
98.2
99.2
0.73
26.6
0.05
30.80
20062007
96.8
98.1
99.5
99.2
99.5
0.97
2.7
0.005
3.25
Antenatal care (4 or more visits)

1996
20062007
52.5
79.1
89.6
94.7
97.2
0.54
44.7
0.10
52.50
92.7
94.5
96.8
98.5
99.4
0.93
6.7
0.01
8.70
Prevalence of contraceptive use

1996
55.8
68.9
73.6
73.8
76.8
0.73
21.0
20062007
82.7
86.0
81.6
83.7
81.6
1.01
1.1
0.05
23.45
0.004
2.25
33.5
49.1
47.4
44.6
47.9
48.0
52.6
50.9
65.1
63.1
0.51
0.78
31.6
14.0
0.11
0.05
34.20
17.15
58.8
57.9
74.4
43.2
30.9c
47.8c
1.90
27.9
0.11
35.25
1.03
1.5
0.03
9.35
Care seeking for acute respiratory

infections
1996
20062007
Oral rehydration salts, commercial
fluids, or homemade solutions
1996
20062007
49.3
57.2
61.7
41.5
Piped water
1996
34.7
70.0
87.0
95.2
99.6
0.35
64.9
0.16
77.50
20062007
75.4
99.6
99.7
99.9
100.0
0.75
24.6
0.04
24.75
Note. Quintile 1 was the poorest; quintile 5 was the richest.

a
Ratio between coverage in the poorest and richest quintiles.
b
Difference between coverage in the poorest and richest quintiles.
c
Based on fewer than 50 observations.
recent trends in wealth inequalities cannot be

assessed.
The noted improvements in nutrition, including the marked reduction in the poorrich
gap in the prevalence of stunting, provide
additional evidence of the countrys strides
toward eliminating health disparities. Brazil has
already achieved the MDG 1 (eradicating extreme poverty and hunger) target indicator for
reducing the prevalence of underweight children younger than 5 years; the prevalence
dropped from 5.7% in 1990 to 1.7% in
2006.43 Given the evidence linking stunting to
childhood mortality and the synergistic relationship between malnutrition, infection, and mortality, the decreases in underweight, stunting, and
wasting during the study period probably contributed to the reductions in the under-5 mortality rate.44 The increasing trends in the prevalence of exclusive breastfeeding and the median
duration of breastfeeding are also probably
responsible for some of the improvements in

infant, neonatal, and postneonatal mortality rates.
The rate of decline in infant mortality slowed
after 2000, although annual rates of reduction
were still above 4%. A possible reason for
this reduced rate of decline is that interventions
introduced in the late 1980s and 1990s targeted at preventing postneonatal deaths had
exerted most of their effect by the year 2000.
New strategies are needed to prevent neonatal
deaths, and these strategies are likely to be
more complex and require greater investment
in the health care infrastructure than those aimed
at reducing postneonatal mortality. Key challenges
include improving continuity between antenatal
and hospital delivery care and, in particular,
ensuring that women know which hospital to
attend for delivery and that this hospital does not
turn them back at any stage of labor.
Another major challenge is reducing the high
rate of cesarean births, which now constitute
almost half of all deliveries in the country. This is

particularly important in light of the higher rates
of neonatal morbidity and mortality associated
with unnecessary cesarean sections.45
Because of differences in methodological
approaches and, until recently, the lack of
investment in producing reliable maternal
mortality data, the available estimates from
Brazil do not allow one to measure trends or
even determine whether MDG 5 will be
reached. The apparent lack of progress in
maternal mortality over the course of the study
period may be an artifact of improvements in
reporting, with maternal mortality audits now
being more widely implemented throughout
the country. According to 2005 interagency
estimates, Brazil is in the moderate category of
maternal mortality (100299 per 100 000 live
births), with an adjusted ratio for that year of
110 per 100 000 live births (95% confidence
interval [CI] = 74, 150).13,46 The lifetime risk of
a maternal death is 1 in 370, in contrast to, for

example, 1 in 17 400 in Sweden.47
Our data showing hypertensive disorders of
pregnancy, sepsis, and hemorrhage as the 3
leading causes of maternal death nationwide as
well as in each region are consistent with global
estimates and reflect gaps in the availability
of high-quality obstetrical and immediate postpartum care services.48 These data, although
showing that greater political and financial commitment to maternal and reproductive health is
needed, mask Brazils improvements in reaching
its population with key interventions critical for
reducing maternal deaths.49
The observed increases in prevalence of
contraceptive use, antenatal care coverage
levels (at least 4 visits), and skilled attendance
at delivery across socioeconomic groups are
indications of Brazils efforts to improve equitable access to essential reproductive health
services. The effects of these positive changes
on maternal mortality may not be captured in
currently available statistics. Studies examining
service quality could provide needed complementary information on how well Brazil is
delivering these core health sector strategies
necessary for the achievement of MDG 5.
Although Brazils maternal and child mortality levels are still too highespecially in
comparison with neighboring South American
countries such as Chile, Argentina, and Uruguayour findings show that the country has
seen sustained decreases in child and infant
deaths and improvements in maternal health
indicators in the past 2 decades. Reasons for
these improvements are attributable to a range
of factors, including socioeconomic and demographic changes and reform measures in the
health and other sectors.
Socioeconomic and Demographic

Factors
Brazil has experienced moderate but sustained growth in recent years and has not been
as negatively affected by the global financial
crisis as other low- and middle-income countries, primarily as a result of its large foreign
reserves, more stable monetary and fiscal
policies, and growing demand for its export
products. In April 2008, Brazil was granted investment grade status, allowing it cheaper access to foreign sources of capital and a lower
cost of debt for government and businesses.50
The country also experienced growth during

the 2000s after increases in access to credit
among lower income families and the introduction of government-sponsored programs
such as Bolsa Familia, a national cash transfer
program. The poorest 30% of families in the
country receive 80% of the programs benefits,
and 60% to 70% of the transfers are being
used for food.5154 There is strong evidence that
the program is well targeted at the poorest
population groups and that dietary quality has
improved since its introduction. However, the
results of impact and coverage evaluations have
been mixed, some suggesting no impact on
nutritional status55 and others suggesting a positive effect.56
The Gini income distribution index declined
steadily from 0.60 in 1990 to 0.53 in 2007,
a 14% reduction,57 and Brazil dropped from the
highest income concentration in the world during the 1980s to a ranking of 14. These trends
are evidence of Brazils progress in addressing its
wide income disparities and may underlie some
of the observed reductions in health gaps between the richest and poorest population groups.
Maternal education has long been recognized as one of the most important determinants of child health and nutrition.58 There
were important improvements in recent years,
particularly among Brazils poorest residents.
The percentage of women in the poorest quintile
with 8 or more years of schooling increased from
5.6% in the 1996 national survey to 29.4% in
the 20062007 survey. Correspondingly, the
percentage of women without any schooling in
the poorest quintile decreased by half, from
11.8% in 1996 to 5.9% in 20062007. Several
recent studies confirm the importance of maternal education for child health in Brazil. Macinko
et al. found a strong association between improvements in womens educational levels and
infant mortality reductions.53,59 Monteiro et al.
carried out a statistical analysis of the decline in
stunting from 1996 to 20062007 and found
that the most important predictor of nutritional
improvement was maternal education.60
Fertility levels in Brazil, e.g., the mean
number of children born by each woman,
have dropped dramatically in the past 3 decades, from a total fertility rate of 4.4 in 1980
to 2.9 in 1991 and 1.8 in 2006.24,61 Brazils
steady fertility decline resulted in a drop in the
number of children younger than 5 years in
the country from 16.3 million in 2000 to

13.8 million in 2007,62 suggesting that
existing services are now better able to cope
with the demand. It is likely that Brazils
downward fertility trend contributed to reductions in the actual numbers and rates of
maternal and child deaths during the study
period.
National-Level Interventions
Broad health sector changes and programs
specifically targeting maternal and child health
were introduced during the course of the study
period and, in all likelihood, contributed to
Brazils observed mortality reductions. As
mentioned, the unified health system providing
universal access to comprehensive health care
was introduced in 1988 as a product of the
new constitution issued at the end of the military
regime. This was followed in 1991 by the
implementation of the Community Health
Agents Program, which provides a restricted
package of health care services delivered primarily by community health workers.
The Family Health Program was then
launched in 1994 (renamed the Family Health
Strategy in 2003) as an effort to reorganize
primary health care by deploying teams of
doctors, nurses, and community health workers
in the countrys poorest areas to deliver a wide
range of primary care services. The program
was rapidly scaled up, reaching 50.7% of the
Brazilian population as of 2010. Several ecological analyses suggest that the Family Health
Program has had a positive impact on infant
mortality,59,63,64 particularly through reduction
of deaths caused by diarrhea.53
A key health reform measure in Brazil has
been decentralization. An ecological analysis of
2700 municipalities accounting for 89% of the
Brazilian population showed that the municipalities with the highest levels of decentralization and primary health care expansion
exhibited the greatest decreases in postneonatal mortality rates from 1998 to 2006.65
Brazil is on track for meeting the MDG 7
water and sanitation targets, reporting that
83% of the population had access to improved sources of drinking water in 1990
and that 91% of the population had such
access in 2006; also, improved sanitation
facilities had reached 77% of the countrys
citizens by 2006, up from 71% in 1990.66
1000 live births in 1990 to 0.8 per 1000 in

2007) and the distribution of these deaths across
all causes would have led to underestimates in
the decline in deaths from infections.
Further analyses of the reasons for the
mortality decline in Brazil can be carried out on
the basis of the data presented here. These may
include formal statistical analyses attempting to
relate the observed trends to changes in socioeconomic, demographic, environmental,
and other determinants, as well as policy
analyses designed to investigate the governmental programs likely to have contributed
most to the decline.
TABLE 6Maternal and Child Health Programs and Policies: Brazil, 19732009
Year of Introduction
Program or Policy
1973
National Immunization Program
1977
Mandatory immunization schedule for infants aged younger than 12 mo
1981
Breastfeeding Promotion National Program
1982
Mandatory rooming-in in maternity hospitals
1984
Program of Comprehensive Child Health Care
1984
1988
Program of Comprehensive Womens Health Care

National Program for Oral Rehydration
1990
Baby-Friendly Hospital Initiative
1995
National Project for the Reduction of Infant Deaths
1997
Integrated Management of Childhood Illness
1998
Program of Humanization of Antenatal Care, Delivery and Childbirth
1999
National Campaign for Birth Registration
Limitations
2000
Regional centers for management of high-risk pregnancies
2001
2001
National Program of Neonatal Screening

National Program for Free Distribution of Contraceptives
2004
National Pact for the Reduction of Maternal and Neonatal Mortality
2009
Pact for Reducing Infant Mortality in the Legal Amazon and Northeast Regions
We have already detailed the limitations of

the data used to describe time trends in
mortality, nutritional status, and intervention
coverage. These limitations include the use of
birth histories for estimating mortality70 and
the use of household assets to establish socioeconomic position.28
In spite of these limitations, there is little
doubt that there were real increases in intervention coverage accompanied by massive
reductions in child mortality and undernutrition. There is also compelling evidence that
regional and socioeconomic disparities were
reduced, in both relative and absolute terms.
Data limitations resulting from improved notification, however, seriously affected examinations of time trends in maternal mortality, and
thus it is not possible to conclude with certainty
whether trends are stable or declining.
Simultaneous improvements occurred in
several determinants of maternal and child
health, including national-level socioeconomic
and demographic changes, a major restructuring and expansion of health care, and specific
maternal and child health programs, and thus
we are not able to identify which of these
changes played the largest role in reducing
child mortality and improving maternal health.
Overall progress was likely due to a combination of these broad improvements.
Note. Data were derived from Rede Inter-Agencial de Informac

xoes para a Saude.72
These coverage improvements may have

contributed to reductions in mortality from
diarrhea during the study period, continuing the significant declines in diarrhearelated child deaths that took place in the
1980s.67
Maternal and Child Health Programs

and Policies
Table 6 displays the primary maternal
and child health programs and policies introduced from 1973 to 2009. These programs
were complemented by strong promotion of
child health activities by the United Nations
Childrens Fund, particularly through close
collaborations with state and municipal governments in the Northeast and North regions.
Nongovernmental organizations including the
Catholic church, through its child pastorate
program; the International Baby Food Action
Network; and the mass media were particularly
active in the areas of infant and young child
feeding, breastfeeding promotion, growth
monitoring, and the promotion of home-based
rehydration solutions, among others.
Establishing a causal relationship between
each of these programs and mortality declines
is beyond the scope of this study. The
achievement of near-universal coverage with

measles and DPT3 immunizations, however, is
an indication of the effectiveness of the National Immunization Program. Likewise, the
marked reduction in diarrhea mortality in the
1980s seems to have been largely due to
improved case management, particularly the
use of oral rehydration.68 The unusual results of
the equity analyses for this indicator (Table 5)
may have been partly attributable to statistical
imprecision (as a result of the small number of
children with diarrhea in wealthier families) or,
alternatively, to stronger promotion efforts
among the poor.
Although an analysis of Brazils Integrated
Management of Childhood Illness program
revealed that it was poorly implemented and
had no measurable impact on mortality
trends,69 our findings on the marked drop in
infant deaths due to infectious diseases, including
diarrhea and pneumonia, suggest that improved
access to health services and case management
has had a positive impact on child health outcomes. It is important to note that the improvements during the study period in the ascertainment of causes of infant deaths (the observed
reduction in the proportion of registered deaths
ascribed to ill-defined causes from 9 deaths per
Conclusions
Brazil has already met the undernutrition
indicator for MDG 1 and is well on track for
achieving MDG 4. Progress toward MDG 5 is
unclear; although coverage of proven reproductive and maternal health interventions has
increased, improved death reportinga sign of

improvement in Brazils vital registration systemsmay obscure any declining trends. The
evidence of reduced socioeconomic and regional inequalities, which have plagued Brazilian society for decades, is as important as the
positive overall trends.
By contrast, the epidemic of cesarean sections,71 the rising trends in preterm births,18 the
difficult challenge of reducing neonatal mortality,71 and the remaining problem of illegal abortions39 are examples of challenges rooted in
health system deficiencies and the sociopolitical
environment that have yet to be tackled in Brazil.
And even if socioeconomic differentials are being
progressively reduced, the actual magnitude
of the poorrich gap in maternal and child
health indicators is still unacceptable. The
continued high levels of infant mortality in the
Northeast and in the poorest population
quintile suggest that considerable effort is still
needed to bring Brazils most disadvantaged
population groups to the level achieved by the
countrys elite.
Our case study provides compelling evidence that proactive actions to reduce health
disparities accompanied by socioeconomic
progress can lead to major improvements in the
health of children and mothers in a relatively
short time period. Our findings from Brazil may
yield important lessons for other low- and
middle-income countries, particularly with respect to their efforts to strengthen health care
systems and address growing health care disparities as essential steps for achieving MDG 4
and MDG 5. Our approach to generating
a comprehensive picture of trends in maternal,
newborn, and child health and relating these
trends to changes in key health determinants
may also prove useful for other low- and
middle-income countries. j
Brazil. Carlos A. Monteiro is with the Department of

Nutrition, School of Public Health, University of Sao Paulo,
Sao Paulo, Brazil. Flavia Bustreo is with the Partnership for
Maternal, Newborn, and Child Health, Geneva, Switzerland. Mario Merialdi is with the Department of Reproductive Health and Research, World Health Organization,
Geneva.
Correspondence should be sent to Fernando C. Barros,
MD, PhD, Rua Marechal Deodoro 1160, 3rd Floor, CEP
96020-220, Pelotas, RS, Brazil (e-mail: fcbarros.epi@
gmail.com). Reprints can be ordered at http://www.ajph.org
by clicking on the Reprints/Eprints link.
This article was accepted May 25, 2010.
Contributors
F. C. Barros, M. Merialdi, and C. G. Victora originated the
study. A. Matijasevich, C. A. Monteiro, and A. J. D. Barros
conducted the analyses. F. C. Barros and C. G. Victora
supervised the analysis, the interpretation of the findings,
and the writing of the article. J. H. Requejo, E. Giugliani,
A. Goretti Maranhao, and F. Bustreo contributed to
the interpretation of the results and assisted with the
editing of the article. All of the authors contributed to the
writing of the article.
Human Participant Protection

No protocol approval was needed for this study.
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About the Authors

At the time of the study, Fernando C. Barros was with the
Postgraduate Course in Health and Behavior, Universidade
Catolica de Pelotas, Pelotas, Brazil. Alicia Matijasevich,
Alusio J. D. Barros, and Cesar G. Victora are with the
Postgraduate Programme in Epidemiology, Federal University of Pelotas, Pelotas, Brazil. Jennifer Harris Requejo is
with the Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD. Elsa Giugliani is with the Brazilian
Ministry of Health, Brasilia. Ana Goretti Maranhao is
with the Assesoria de Projetos Especiais da Fundacxao de
Ensino e Pesquisa do Governo do Distrito Federal, Brasilia,
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