Epidemiological transition, medicalisation of childbirth, and neonatal mortality: three Brazilian birth-cohorts

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Over the past two decades, Brazil has seen improvements in women’s nutritional status, education, smoking habits, and antenatal care. Neonatal mortality rates (deaths of liveborn infants up to 1 month of age), however, have changed little. In this issue of The Lancet, Fernando Barros and colleagues present fascinating data from three birth-cohorts which suggest that falling mortality in term infants (37 weeks’ gestation or more) has been offset by a rise in preterm births and deaths, resulting in little change in neonatal mortality. Brazilian health authorities can claim fairly that more preterm infants survive because of better neonatal care: gestation-specific mortality rates have fallen by 50% since 1982. Nonetheless, many preterm deliveries result from pregnancy interruption, either by caesarean section or induction. Such early delivery is often a direct consequence of inappropriate medicalisation.
The road to hell is paved with good intentions, and efforts to improve perinatal care have often had unintended consequences.1 Diethylstilbestrol was used in millions of pregnancies before its association with vaginal cancer in offspring was noted. Uncontrolled use of oxygen and sulphonamides to treat respiratory distress in premature infants in the 1950s triggered epidemics of retinopathy and kernicterus, respectively. A proportion of the epidemic of sudden infant deaths was attributable to paediatricians encouraging prone sleeping for term infants, drawing incorrectly on their experience of nursing preterm infants in this position to avoid aspiration.2 Arguably the most pernicious example of medicalisation, however, is the promotion of formula milks. The increased health risks of formula feeding have been well documented in communities where illiteracy, poverty, and lack of a clean supply of water are the norm. Formula-fed infants aged under 2 months are nearly six times more likely to die than breastfed infants,3 but inappropriate promotion by milk companies remains widespread.

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