What is the profile of neonatal deaths in Brazil and the main associated problems?

Responsible researcher: Viviane Pires Ribeiro

Article title: BIRTH RESEARCH IN BRAZIL: NEONATAL MORTALITY PROFILE AND EVALUATION OF CARE FOR PREGNANT WOMEN AND NEWBORN

Authors of the article: Sônia Lansky, Amélia Augusta de Lima Friche, Antônio Augusto Moura da Silva, Deise Campos, Sonia Duarte de Azevedo Bittencourt, Márcia Lazaro de Carvalho, Paulo Germano de Frias, Rejane Silva Cavalcante and Antonio José Ledo Alves da Cunha

Location of intervention: Brazil

Sample size: Medical records of 23,940 mothers

Sector: Healthcare

Type of Intervention: Determine the profile of neonatal deaths identified in the Birth in Brazil Survey and associated factors

Variable of main interest: Infant mortality

Assessment method: Other

Assessment Context

Since the 1990s, Brazil has maintained high levels of neonatal mortality, with a rate of 11.2 deaths per thousand live births in 2010. The infant mortality rate in the country in 2011 was 15.3 per thousand live births . Although births predominantly occur in hospitals (98.4%) and are attended by doctors (88.7%), the results are unsatisfactory when compared to other locations in the world that have achieved lower neonatal and infant mortality rates. These mortality levels in Brazil may be a reflection of the unfavorable living conditions of the population and health care, in addition to historical regional and socioeconomic inequalities.

The main component of infant mortality in Brazil is early neonatal mortality (0-6 days of life) and a large proportion of infant deaths occur in the first 24 hours (25%), indicating a close relationship with care during labor and birth. According to the literature, the main causes of death are prematurity, congenital malformations, intrapartum asphyxia, perinatal infections and maternal factors, with a considerable proportion of deaths preventable through the actions of health services.

Intervention Details

Lansky et al. (2014) analyze the profile of neonatal deaths identified in the National Birth Survey in Brazil and the associated factors, considering the socioeconomic and demographic contextual aspects, the characteristics of the pregnant woman and the newborn and the care process in prenatal care, childbirth and birth.

The Birth in Brazil National Survey is a hospital-based study composed of postpartum women and their newborns, carried out from February 2011 to October 2012. The sample was selected in three stages: the first stage was composed of hospitals with 500 or more births/year stratified by the five macro-regions of the country, location (capital or non-capital), and type of hospital (private, public and mixed); the second was composed of days (minimum of seven days in each hospital); and the third composed of postpartum women. In each of the 266 hospitals sampled, ninety postpartum women were interviewed, totaling 23,940 subjects.

Methodology Details

In the cohort study, the outcome variable analyzed was neonatal death, defined as deaths of live births regardless of birth weight and gestational age, which occurred before the 28th day of life. To identify neonatal deaths that occurred during the research period and obtain information, the authors linked the database with neonatal deaths that occurred in Brazil in 2011 and 2012 with the Mortality Information System (SIM) and Information System on Live Births (SINASC).

OpenRecLink program was used for the probabilistic linkage of records using the variables mother's name, date of birth, sex of the newborn and date of death, in three stages: standardization, blocking and pairing of records; the pairs were classified as true, false and doubtful, with manual review, according to the process described by Camargo Jr. & Coeli.

For the hierarchical modeling to determine neonatal death, the exposure variables were divided into four blocks: socioeconomic and demographic; past history and current pregnancy; birth assistance process; and general conditions of the newborn and newborn care.

Results

The study identified 24,061 live births and 268 neonatal deaths between the period of February 2011 and October 2012, resulting in a weighted neonatal mortality rate of 11.1 deaths per thousand live births. Deaths were concentrated in the Northeast (38.3%) and Southeast (30.5%) regions of Brazil and among premature newborns and those with low birth weight (81.7% and 82%). The Southeast, Central-West and South regions had the highest proportion of preterm deaths. Extreme prematurity (< 32 weeks) and very low birth weight (< 1,500g) represented 60.2% and 59.6% of deaths, respectively, with higher proportions in the Central-West and Southeast regions. The highest proportion of deaths of full-term newborns occurred in the Northeast (21.3%).

Regarding care markers and those related to the organization of the health system, the results show that the majority of deaths occurred in SUS hospitals, 50% of those weighing < 1,500g were born in a hospital without a neonatal ICU, 23.3% of mothers they had inadequate prenatal care with a risk of neonatal death four times higher and around 40% went abroad at the time of birth and did not have a companion during hospitalization for the birth. The partogram was rarely used to monitor labor, whether among newborns who survived (35.7%) or among those who died (36.5%). Therefore, the pilgrimage of pregnant women for childbirth and the birth of children weighing < 1,500g in a hospital without a neonatal ICU demonstrated gaps in the organization of the health network.

The variables that remained associated with neonatal death were, in descending order according to the magnitude of the association: very low birth weight; mechanical ventilation; congenital malformation; birth asphyxia; maternal complications during pregnancy; pelvic presentation; twinning; low maternal education, North and Northeast regions, previous stillbirth; pilgrimage for childbirth; not using a partograph during labor; inadequacy of prenatal care; mother without a partner; previous premature; referral hospital for high-risk pregnancies; male sex.

Public Policy Lessons

What is the profile of neonatal deaths in Brazil and the main associated problems? The study carried out by Lansky (2014) indicated that between February 2011 and October 2012, the neonatal mortality rate was 11.1 per thousand. Being higher in the North and Northeast regions and in the lower social classes. Low birth weight, gestational risk and newborn conditions were the main factors associated with neonatal death. In this sense, the authors point out that progress in reducing neonatal mortality and, consequently, infant mortality – as well as maternal death and preventable fetal death, whose related care problems are similar – will depend on the consolidation of an integrated perinatal network, hierarchical and regionalized, and the qualification of care processes, especially labor and birth.

Therefore, the qualification of care, especially hospital care during childbirth, is a priority focus for further advances in public policies to reduce rates and inequalities in infant mortality in Brazil.

References

LANSKY, Sônia et al. Birth in Brazil Survey: profile of neonatal mortality and evaluation of care for pregnant women and newborns. Public Health Notebooks, v. 30, p. S192-S207, 2014.