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Assessing the Effectiveness of S and#195;and#402;and#194;and#163; o Paulo and#195;and#162;and#194;and#8364;and#194;and#8482; s Policy Efforts in Lowering Teenage Pregnancies and Associated Adverse Birth Outcomes
ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Assessing the Effectiveness of S ã o Paulo ’ s Policy Efforts in Lowering Teenage Pregnancies and Associated Adverse Birth Outcomes

Alexandra Brentani1*, Gunther Fink2, Maria Lucia Bourroul3 and Sandra JFE Grisi1
1Faculdade de Medicinada Universidade de São Paulo, Brazil
2Harvard School of Public health - Department of Global Health and Population, Brazil
3Secretaria Municipal de Saúde, Prefeitura de São Paulo, CEINFO, Brazil
Corresponding Author : Alexandra Brentani
Faculdade de Medicinada Universidade de São Paulo, Brazil
Tel: 55 11 983319050
E-mail: [email protected]
Received December 15, 2014; Accepted April 16, 2015; Published April 18, 2015
Citation: Brentani A, Fink G, Bourroul ML, Grisi SJFE (2015) Assessing the Effectiveness of São Paulo’s Policy Efforts in Lowering Teenage Pregnancies and Associated Adverse Birth Outcomes. J Preg Child Health 2:151. doi: 10.4172/2376-127X.1000151
Copyright: © 2015 Brentani A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Objective: To assess the impact ofBrazil’spolicyefforts introduced in 2008 to reduceadolescent fertility rates as well as improve adolescent birth outcomes in the São Paulo metropolitan area of Brazil. Methods: Pregnancy records for teenage mothers for the entire municipality were retrieved from theMunicipality Health Secretariat’s Information System for the period 2004 to 2011. Records extracted included information on the number of prenatal consultations, delivery modality, gestational length, and birth weight and survival status for teenage mothers. Two-sample mean difference tests were computed to compare the pre-period 2004-2007 tothe post- period 2008-2011 both for the aggregate São Paulo municipality, and each of the five regions in the municipality. Results: Adolescent fertility rates declined from 52.2 to 50.8 births per 1000 females of age 15-19 in the municipality from the (pre) period 2004-2007to the (post) period 2008-2011 (β=-1.5, p-value <0.001). The largest decrease in adolescent fertility was observed in the center-western region (β= -3.2, p-value <0.001), while the southern region experienced a small but statistically insignificant increase in adolescent fertility (β=0.2, p-value=0.669).Over the same period, access to prenatal care among adolescent mothers improved, with the fraction of teenage mothers reporting less than seven antenatal care visits declining from 41.4% in the pre- to 37% in the post period (p-value < 0.001). While the risk of low birth weight declined marginally (β=-0.003, p-value=0.041), no differences were observed with respect to preterm birth and modality of delivery. Surprisingly large increases were found in the likelihood of teenage pregnancies resulting in stillbirth, from 1.8 stillbirths per 1000 deliveries in the pre-period to 4.3 deaths per 1000 teenage deliveries after the introduction of the policy efforts. Discussion and Conclusion: The findings presented suggest that teenage fertility rates have declined marginallybetween the pre-and post-reform periods. Given the relatively large increase in the number of stillbirths over the same period, the overall program impact on teenage pregnancies is likely limited. While the observed increases in stillbirthsmay at least partially reflect changes in the reporting of stillbirth, further research will be needed to better understand these unexpected trends. More generally, further efforts and new strategies to prevent teenage pregnancies will need to be considered if the government objectives of achieving large reductions in teenage fertility are to be achieved.

Teenage pregnancy; Adverse birth outcomes; Teenage fertility rate; Pre-natal care; Public policy
Teenage pregnancies have received increased attention from policy makers and health service researchers in recent years, not onlybecause of the potentially large detrimental impact of teenage pregnancies on mother’s health and livelihood, but also because of the generally adverse consequences for the child [1-3]. A large literature has investigated the causes and determinants of teenage pregnancy, frequently with the objective of reducing pregnancy rates in this age group [4-7] which are generally perceived to be too high [8-10]. To some extent, the increasedrelative frequency of teenage pregnancies can be attributed to the globally declining age of menarche [1,11], and the earlier onset of sexual activity. Nevertheless, from a policy and welfare perspective, teenage pregnancies are generally of particularly concern due to the rather high concentration among lower socioeconomic status groups [12-15]. As a result of teenage pregnancies, these groups experience worse pregnancy and birth outcomes in terms of gestational length, birth weight and labor and birth complications [16-18]. While estimates appear to vary substantially across studies, the risk of low birth weight among teenage mothers appears to be twice as large as compared to adult mothers, with 14% of babies born pre-term [19-22].
In addition to the increased risk of adverse pregnancy and birth outcomes, a growing body of epidemiologic research has linked intrauterine and early life adversity to later life impairments, such as chronic disease, cognitive development impairment or mental disorders [23-25]. From a biological perspective, teenage pregnancies pose a challenge to the developing child, which may not be able to receive sufficient resources from their young mothers who are still developing physically [1,2,11]. Beyond the biological challenges, teenage mothers are generally less educated and less mature emotionally, and may thus not be able to provide the support and stimulation needed for the child’s adequate development [26-30].
Partially in an effort to achieve the Millennium Development Goals, the Brazilian government has been making major efforts to reduce infant mortality rates in general and neonatal death rates in particular. Through the “Pact for life” program launched in 2006, the Brazil Ministry of Health established agoal of a 5% reduction in neonatal mortality and other 40 indicators revised every year. To reduce pre-term deliveries and low birth weight[31], the “Pact forlife” program includedcomprehensive pre-natal care programs, and also an explicit focus on establishing the prevention ofteenage pregnancies as a primary care priority. In 2007, the Ministry of health established a new regulatory framework for adolescent sexual and reproductive health (Marco teórico e referencial Saúde sexual e saudere produtiva de adolescents e jovens). The framework definesand establishes teenagers’ rights to freely exercise their sexuality, to have unrestricted access to information about family planning methods and to use family planning. In response to this new framework, the national health council established - through the “Politicanacional de atenção integral à saúde de adolescents e jovens” - new guidelines for the primary health care sector requiring them to offer the following services to adolescents: counselling and education, easy access to family planning and free provision of sexual disease treatment, facility delivery and postnatal follow-ups. As part of these effects, new educational programs were developed, offering training for primary care health providers, and creating an integrated network to attend and support victims of violence [32,33].In 2007, more ambitious than the national program, the municipality of São Paulo2008 set a goal of 72.1% coverage of adequate antenatal care (7 or more visits) for the 2008/2009 period and 76.1% for the 2010/2011 period through the “Pact for Health”. In addition, through the “Family Health Program evaluation and monitoring system”a goal of a 10% reduction in teenage fertility over and above the national objectives in 2008 was set for the municipality [34,35].
The aim of this study is to investigate whether the recent policy efforts made at the national and municipality level have been effective in a) reducing adolescent fertility rates; and b) reducing the health risks associated withadolescentchildbearing.
Study setting and study population
The data used in this study covers all five administrative regions of São Paulo Municipality. In 2010, the total population of the entire areas was estimated at 11,377,021. Administratively, São Paulo Municipality is divided into five regions: the Center-Western region (13% of total population), the Eastern region (21%), the Northern region (19%), the Southwestern region (24%) and the Southern region (23%).With a crude birth rate of 15.6 per 1000 population, the population is relatively young, with about 15.2 percent of the population in the 10-19 age range. In terms of child health, the municipality fares substantially better than the national (Brazilian) average, with an estimated infant mortality rate of 11.4 per 1000 live births nearly 50% below the country average 20 deaths per 1000 [34]. In terms of socio-economic status, São Paulo’ Human Development Index of 0.84is 20% above the national average of0.70, with large variations within and across regions. 12.2% of theSão Paulo population lives in slums; the share of slum residents varies from 7.4% in the Center-Western region to 21.6% in the Southern Region [36]. With respect to health services, 37.10% of families are currently covered under the comprehensive Family Health Program (PSF) in 2011, while the rest are either covered by the traditional (free) public health care model or in the private health sector.
Since 2000, the Municipality’s Health Secretariat has been responsible for the collection of complete vital registration data in the Municipality. Through the Sistema de Informações de Nascidos Vivos (SINASC) data collection and information flow is regulated as specified in Act Nº 325/2004. Mortality information is collected through the Programa de Aprimoramento de Informaçõessobre Mortalidade (PROAIM) created in 1989 (Act Nº 28.187). Since the creation of both programs, all births and deaths in the municipality are mandatorily registered in their databanks. Additional backup reporting systems have been established to ensure that deaths of municipality residents outside of São Paulo are fully captured in the system. For the present study, all available data as of May 29 2013 was extracted from both the SINASC and PROAIM systems. Additional information was added fromt the Population Census as represented in the “Censo IBGE 2010, Estimativas 1996-2011 Fundação SEADE” data base.
Outcome variables
The primary outcome variable analyzed was adolescent fertility. Adolescent fertility rate was defined as the number ofadolescent live birthsper 1000 women of ages 15-19. Additional outcomes analyzed were the number of antenatal care visits,gestational length, and type of delivery,birth weight and stillbirths. Following national guidelines, we coded antenatal care as “adequate”, if the mother benefitted from at least seven antenatal care visits. Births were classified as preterm if gestational length was <37 weeks.Births were classified as low-birth weight if birth weight was less than 2500g. Births were classified as stillbirth if the baby was at least 22 weeks old at birth, weighing more than 500g and born without sign of life.We also analyzed the frequency ofcesarean sections. Cesarean sections are sometimes used as proxy of cephalopelvic disproportion, even though their high prevalence in Brazil suggests that they are likely to reflect preferences of mothers and medical staff more than medical need [1,37].
Statistical analysis
While the “Pact of Life” program was technically initiated in 2006 in the national level, the Municipality’s “Pact of Health” comprising health indicators and goals became fully operational until 2008. Accordingly we divided the sample period in the pre period of 2003- 2007, and the post-period of 2008-2011. Two-sample mean difference tests were computed to compare the pre-and the post- periods both for the aggregate São Paulo municipality, and each of the five regions in the municipality.
Statistical analysis was performed using the Stata © 12 statistical software package.
Ethical clearance
The project was approved by the Medical School Internal Review Board under protocol number 328/12.
Table 1 shows the main results for adolescent fertility. Adolescent fertility rates declined from 52.2 live births per 1000 female adolescents in the 2003-2007 periods to 50.8 in the post period (p-value < 0.001). Substantial variations were found both with respect to the level and trends of adolescent fertility, with lowest levels in the Western and South-Eastern regions (35.6 and 39.3, respectively) and highest levels in the Southern and Eastern regions (58 and 56.3, respectively). Overall, little evidence was found for convergence, with the largest absolute declines observed in the Western region (-3.2, p-value <0.001), which already had the lowest rates in the pre-period, and smallest declines (an actual increase) observed in the Southern region, which ranks among the worst-performing regions (0.2, p-value 0.67).
Figure 1 compares the trends in adolescent fertility rates for the five regions of São Paulo to the trends in São Paulo municipality overall, as well as to the trends at the national level. Overall adolescent fertility rates were substantially higher in Brazil than in São Paulo, with average levels of 80.8 live births per 1000 adolescents in the pre-period. Adolescent fertility rates declined to 74.1 live births in the post-period. The 8% decline in adolescent fertility at the national level over the study period is similar in relative terms to the decline observed in the Western region, and substantially larger than the declines observed in the four other regions and São Paulo overall (Table 1).
Table 2 shows the results for antenatal care visits by adolescent mothers. Lack of adequate antenatal care (less than 7 visits) decreased by 4.6 percentage points in the region overall (p-value <0.001). Largest improvements were observed for the Southern region, with a decrease of inadequate prenatal care from 0.45 to 0.36 percentage points (p-value<0.001). The only region where no improvements in antenatal care attendance was observed was the Northern region, which was the best-performing region in the pre-period, but then experienced an increased from 0.38 to 0.41 (p-value <0.001).
Table 3 shows the fraction of pre-term births in adolescent pregnancies. Albeit some regions experienced a small decline, the fraction of pre-term birth in the municipality as a whole appeared roughly constant with rates close to 10%. Similar patterns were also observed for low birth weight (Table 3, second panel), with an average (not-statistically significant) decline from 0.111 to 0.108. No major changes were found for Cesarean section deliveries among teenagers, which remained constant at in a level close to 30%, substantially below the national and local average.
Table 4 shows trends in stillbirths among teenagers. Overall, the number of teenage stillbirths increased substantially from 1.8 per 1000 in 2004-2007 to 4.3 per 1000 in 2008-2011 (p-value<0.001), with increases observed across all regions of São Paulo. Increases were largest in the Eastern region (0.032), and smallest in the Western region (0.013), somewhat opposite to the patterns observed for prenatal care (where Eastern province performs better than all other regions).
The analysis presented in this paper has yielded both positive and negative results from a health system perspective. On the positive side, adolescent pregnancies appear rare in São Paulocompared to the larger national or regional (South-American) populations, and are associated with a relatively low risk of early delivery or low birth weight. On average, the data presented in this paper suggests that less than 10% of children delivered by teenage mothers are born preterm, and that less than 11% are born with birth weight below 2.5kilograms. Over the period analyzed, most regions showed progress regarding adverse birth outcomes, with the exception of the Southern region, which remained constant in terms of pre-term births and low birth weight, but produced worse results in terms of adolescent fertility rates, cesarean sections and stillbirths, even though this region showed bigger efforts in terms of ante-natal adequate coverage.The principal negative result with respect to birth outcomes in the Municipality as a whole was the pronounced increase in stillbirths observed. According to the Municipality Health Secretariat, no study has yet investigated the causes of these increases. However, given that the Municipality has made a major effort to improve the reporting of stillbirth after 2010, one possibility is clearly that the observed trends represent improved reporting over time rather than actual changes in health risk - further research is needed to better assess the true risk of stillbirth in this population and to identify the causal factors underlying these changes.
In terms of the “Pact for Life” policy, the results suggest that recent government efforts may have been successful in reducing adolescent fertility, even though the achieved 3% reduction in the first three years after the reform falls substantially short of the 10% reduction targeted by the Municipality Health Secretariat in 2008. Given that the number of still births appears to have increased over the time period, it is not clear at all whether there has been any change in the total number of teenage pregnancies over the study period. In terms of policy, particular focus will likely be necessary for antenatal care, with 37% of teenage mothers still not benefitting from the full service package. When the Health Municipality Secretariat launched the teenage pregnancy efforts in 2008, major importance was given to access of pre-natal care and teenage pregnancy follow-up programs. Although the “MãePaulistana”, São Paulo’s Municipality pre-natal program, is very comprehensive and primary care units were especially attentive in providing access to teenage mothers, the established goals ofreducing the percentage of mothers receiving at least seven antenatal care visits (36.7 for 2009 and 23.9 for 2011) were not achieved.From a policy perspective, it is not obvious why the targets were not reached; the programs main focus was access to contraception and (reproductive) health education, which have been highlighted as important predictors of teenage pregnancies in the past [5,9,27,38-40]. Anecdotal evidence suggests that primary health providers did indeed provide access to a comprehensive set of contraceptive methods to any teenager seeking care. The lacking impact of these policies suggest that lacking awareness of, and lacking access to, family planning are likely not among the key barriers to lower teenage fertility rates in this setting.
The study has several important limitations. First, and most importantly, the basic two period comparisons of birth outcomes does not allow us to directly attribute the observed changes in birth outcomes to the 2008 policy change or specific government efforts. While it appears plausible that the policy change did indeed contribute to the observed changes, it is likely that other factors such as increases in education and income also contributed to the improvements documented over the sample period. Given the national level of the program, identifying a plausible reference group is not obvious. From an aggregate perspective, both average income and education increased over the study period. While fertility behavior tends to change slowly, it is clearly possible that both factors contributed to a reduction in adolescent fertility, so that the true effect of the program may be smaller than the numbers reported in this paper.
The second major limitation of the paper is the focus on birth rather than pregnancy outcomes. Given that a substantial fraction of teenage pregnancies are likely to end in miscarriage or abortion, pregnancy trends may look fundamentally different from the fertility trends presented here. With a large amount of social pressure and stigma associated with teenage pregnancies, more detailed qualitative studies will be needed for provide a more complete understanding of teenagers’ reproductive health.
Reducing adolescent fertility was declared one of primary health care prioritiesby São Paulo Health Secretariatin 2008. This paper suggests that adolescent fertility rates have been declining in the municipality as a whole in recent years, even though rates varied substantially across regions. With adolescent fertility rates above 50 per 1000 in most parts of São Paulo, substantial further reductions in adolescent fertility rates seem both feasible and desirable from a maternal and child health perspective.
The authors would like to thank the Municipality Health Secretariat (CEINFO) for their help and the Harvard Center on the Developing Child, Harvard David Rockefeller Center for Latin American Studies and Núcleo Ciênciapela Infância for their support.

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