Principal investigator: Viviane Pires Ribeiro
Article title: RESEARCH ON BIRTH IN BRAZIL: PROFILE OF NEONATAL MORTALITY AND EVALUATION OF CARE FOR PREGNANT WOMEN AND NEWBORNS
Article authors: 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 the intervention: Brazil
Sample size: Medical records of 23.940 mothers
Sector: Health Insurance
Type of Intervention: To determine the profile of neonatal deaths identified in the "Born in Brazil" survey and the associated factors.
Primary variable of interest:Infant mortality
Evaluation method: Other
Evaluation 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 reflect unfavorable living conditions for the population and healthcare, as well as 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 within the first 24 hours (25%), indicating a close relationship with childbirth and delivery care. According to the literature, the main causes of death are prematurity, congenital malformation, 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 Survey Born in Brazil and the associated factors, considering socioeconomic and demographic contextual aspects, the characteristics of the pregnant woman and the newborn, and the care process during prenatal care, childbirth, and the newborn period.
The National Survey of Birth in Brazil is a hospital-based study composed of postpartum women and their newborns, conducted between February 2011 and October 2012. The sample was selected in three stages: the first stage consisted of hospitals with 500 or more births per 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 stage consisted of days (a minimum of seven days in each hospital); and the third stage consisted of postpartum women. In each of the 266 sampled hospitals, 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, that occurred before the 28th day of life. To identify neonatal deaths that occurred during the research period and to obtain information, the authors linked the database to neonatal deaths that occurred in Brazil in 2011 and 2012 using the Mortality Information System (SIM) and the Live Birth Information System (SINASC).
The program OpenRecLink The method was used for probabilistic record linkage using the variables mother's name, date of birth, newborn's sex, and date of death, in three stages: standardization, blocking, and record matching; 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 of neonatal mortality determination, the exposure variables were divided into four blocks: socioeconomic and demographic; past history and current pregnancy; delivery care process; and general conditions of the newborn and newborn care.
Results
The study identified 24.061 live births and 268 neonatal deaths between February 2011 and October 2012, resulting in a weighted neonatal mortality rate of 11,1 deaths per 1,000 live births. Deaths were concentrated in the Northeast (38,3%) and Southeast (30,5%) regions of Brazil, and among premature and low birth weight newborns (81,7% and 82%). The Southeast, Central-West, and South regions presented the highest proportion of preterm deaths. Extreme prematurity (< 32 weeks) and very low birth weight (< 1.500g) accounted for 60,2% and 59,6% of deaths, respectively, with higher proportions in the Central-West and Southeast regions. The highest proportion of term newborn deaths occurred in the Northeast (21,3%).
Regarding care markers and those related to the organization of the health system, the results show that most deaths occurred in SUS (Brazilian public health system) hospitals, 50% of those weighing < 1.500g were born in hospitals without a neonatal ICU, 23,3% of mothers had inadequate prenatal care with a four times higher risk of neonatal death, and about 40% wandered around during childbirth and did not have a companion during their hospital stay for delivery. The partogram was rarely used to monitor labor, both among newborns who survived (35,7%) and those who died (36,5%). Therefore, the wandering of pregnant women for childbirth and the birth of children weighing < 1.500g in hospitals 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; breech presentation; twin pregnancy; low maternal education; North and Northeast regions; previous stillbirth; travel for childbirth; non-use of a partogram during labor; inadequate prenatal care; mother without a partner; previous premature birth; referral hospital for high-risk pregnancy; male sex.
Lessons in Public Policy
What is the profile of neonatal deaths in Brazil and the main associated problems? The study conducted by Lansky (2014) indicated that between February 2011 and October 2012, the neonatal mortality rate was 11,1 per thousand. This rate was higher in the North and Northeast regions and among 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, hierarchical, and regionalized perinatal network, and on the improvement of care processes, especially during childbirth and delivery.
Therefore, improving the quality of care, especially hospital care during childbirth, is a priority for further progress in public policies aimed at reducing infant mortality rates and inequalities in Brazil.
References
LANSKY, Sônia et al. Research on Birth in Brazil: profile of neonatal mortality and evaluation of care for pregnant women and newborns. Cadernos de Saúde Pública, v. 30, p. S192-S207, 2014.
