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    • While several recent studies have shown

    2018-11-02

    While several recent studies have shown positive correlations between FHS coverage at the endothelin receptor antagonists level and child health outcomes (Brandao, Gianini, Novaes, & Goldbaum, 2011; Macinko et al., 2007; Rasella, Aquino, & Barreto, 2010a, 2010b; Reis, 2014; Rocha & Soares, 2010), the existing literature primarily relies on comparing changes in health outcomes across administrative areas or changes in outcomes within administrative areas over time using panel models. Most of this work builds on the assumption that the rollout and scaling up of the FHS is random, and that population level associations in this setting are representative of the associations between health outcomes and FHS exposure at the individual level, which is not obvious in this setting.
    Methods
    Study population The study population comprised all infants born at the University Hospital between April 1, 2003 (when electronic records were introduced) and November 30, 2012. The University Hospital (HU-USP) is the main public general hospital of the Butantã-Jaguaré region, covering 82% of the births by women covered exclusively by the public national health system (SUS) and about 40% of all births in the region in 2012 (Prefeitura de SP Saúde, 2012).
    Hospital birth records We retrieved detailed electronic records for all deliveries from the hospital’s electronic system, including gestational length, birth weight, delivery mode, APGAR scores and survival status at birth. Births were classified as low birth weight if birth weight was less than 2500g. Births were classified as pre-term if the estimated gestational length was less than 37 weeks.
    Child mortality outcomes
    Determining FHS eligibility To determine whether a birth was covered by the FHS program, mothers’ residential addresses were retrieved from the University Hospital’s electronic system and geocoded. Geocoded addresses were then cross-referenced against period-specific FHS coverage maps provided by the health district office (Secretaria Municipal de Saúde). In the study area, FHS coverage was gradually scaled up in the region between 2001 and 2012 (see Supplemental Information Figures S2 and S3 for details), reaching about 40% the study population by 2012. Births were considered as eligible for FHS if the mother’s home address at the time the child was conceived fell within an area covered by operational FHS teams.
    Statistical analysis and empirical strategy To assess the impact of the FHS model we estimate multivariate logistic models, which explore variations in FHS coverage conditional on area and birth cohort fixed effects. The model estimated can be described as follows:where is the outcome of interest for child i born in area j and year t, FHS is an indicator for whether the area was covered by a FHS team when the child was conceived, X is a vector of maternal characteristics, and are catchment area (primary health care center) and year fixed effects. In the empirical model, the year fixed effect capture both generic time trends and temporal mortality shocks at the regional level. The area fixed effects capture all time-indifferent variations in local socioeconomic characteristics, health and health care access at the level of the primary health unit. Each observation in our sample corresponds to a birth recorded at Sao Paulo University Hospital between 2003 and 2012. FHS treatment is assigned based on children’s residence and the month of the child’s birth. The assignment of FHS teams is generally done within catchment areas of a given primary health care facility, so that only a certain percentage of mothers from each catchment area benefits from the program. The primary outcome of our analysis is child mortality. However, given the explicit focus of the FHS on prenatal care, we also analyze the following pregnancy outcomes: low birth weight, preterm birth, small for gestational age, stillbirth and Cesarean delivery. Recent reviews suggest that the likelihood of the first four negative outcomes should be reduced through appropriate antenatal care in general (Dowswell et al., 2010) and micronutrient supplementation in particular (Haider & Bhutta, 2015); the same should hold true for cesareans to the extent that they are used to resolve delivery complications.