Fatores de risco para mortalidade neonatal precoce

Determinants of Neonatal and Postneonatal Mortality in Northeastern Brazil: A Cohort Study of Newborns Admitted to the Neonatal Intensive Care Unit

Despite advances in neonatology, neonatal mortality from preventable causes remains high in the North and Northeast regions of Brazil. This study aimed to analyze the determinants associated with neonatal and postneonatal mortality in newborns admitted to a neonatal intensive care unit. A cohort study was carried out in a capital in the Brazilian Northeast from 2013 to 2018. The outcome studied was death. Poisson regression was performed in the multivariate analysis of variables. Four hundred and eighty newborns were eligible, and 8.1% (39 newborns) died. Among them, 34 died in the neonatal period. The determinants that remained significantly associated with neonatal and postneonatal mortality in the final adjustment model (p < 0.05) were history of abortion, perinatal asphyxia, early neonatal sepsis and umbilical venous catheterization. All causes of this outcome were preventable. The neonatal mortality rate, although it did not include twins, neonates with malformations incompatible with life and other conditions, was 3.47 deaths per thousand live births (95% CI:1.10-8.03‱), well below the national average. In this study, pregnant women from different social classes had in common a private plan for direct access to health services, which provided them with excellent care throughout pregnancy and postnatal care. These results indicate that reducing neonatal mortality is possible through public policies with strategies that promote improvements in access to health services.

Sociodemographic, behavioral, obstetric, and healthcare factors associated with low weight at birth: a case-control study

BACKGROUND

Understanding social determinants is crucial for implementing preventive strategies, especially for low birth weight (LBW)-a public health issue that severely increases the risk of morbimortality in children.

OBJECTIVE

This study aimed to identify the factors associated with LBW among newborns, assisted by the Brazilian Unified Health System.

DESIGN AND SETTING

It analyzed data from newborns and their mothers. The sample was selected by convenience from users of the public health system in Francisco Beltrão (Paraná, Brazil).

METHODS

Cases (n = 26) were babies weighing ≤ 2,500 g and controls (n = 52) > 2,500 g. All babies were assessed and paired by sex and date of birth in a 1:2 proportion. Statistical power was computed a posteriori, revealing a power of 87% (α = 0.05).

RESULTS

Strong and significant differences were found in the bivariate analysis, in which the number of current smokers or those who quit during pregnancy was higher among mothers of babies with LBW. Moreover, the gestational weeks were lower among these cases. Logistic regression models indicated that the gestational week (odds ratio [OR] = 0.17, 95% confidence interval [CI]:0.05-0.54) and fathers' educational level (high school or above; OR = 0.22, 95% CI:0.06-0.99) were related to lower chances of low birth weight.

CONCLUSIONS

Our findings confirm previous investigations on LBW's multi-causality, showing that the gestational week could reduce up to 82% chances of a baby being born with ≤ 2,500 g. Its association with paternal education underlines the importance of comprehensive policies to protect newborns.

LIVE BIRTHS OF IMMIGRANT MOTHERS IN BRAZIL: A POPULATION-BASED STUDY

Introduction

Methods

Results

Conclusion

Perinatal Mortality Analysis in Espírito Santo, Brazil, 2008 to 2017

This is an ecological and time-series study using secondary data on perinatal mortality and its components from 2008 to 2017 in Espírito Santo, Brazil. The data were collected from the Mortality Information System (SIM) and Live Births Information System (SINASC) of the Unified Health System Informatics Department (DATASUS) in June 2019. The perinatal mortality rate (×1000 total births) was calculated. Time series were constructed from the perinatal mortality rate for the regions and Espírito Santo. To analyze the trend, the Prais-Winsten model was used. From 2008 to 2017 there were 8132 perinatal deaths (4939 fetal and 3193 early neonatal) out of a total of 542,802 births, a perinatal mortality rate of 15.0/1000 total births. The fetal/early neonatal ratio was 1.5:1, with a strong positive correlation early neonatal mortality rate, perinatal mortality rate, r (9) = 0.8893, with a significance level of p = 0.000574. The presence of differences in trends by health region was observed. Risk factors that stood out were as follows: mother's age ranging between 10 and 19 or 40 and 49 years old, with no education, a gestational age between 22 and 36 weeks, triple and double pregnancy, and a birth weight below 2499 g. Among the causes of death, 49.70% of deaths were concentrated in category of the tenth edition of the International Classification of Diseases, fetuses and newborns affected by maternal factors and complications of pregnancy, labor, and delivery (P00-P04), and 11.03% were in the category of intrauterine hypoxia and birth asphyxia (P20-P21), both related to proper care during pregnancy and childbirth. We observed a slow reduction in the perinatal mortality rate in the state of Espírito Santo from 2008 to 2017.

Will Brazil comply with the SDG 3.1 of the 2030 Agenda? An analysis of maternal mortality, from 1996 to 2018

This article aims to analyze if it is possible for Brazil to meet the Sustainable Development Goals (SDG) 3.1, based on a diagnosis of the situation of maternal mortality in the Health Regions (HRs) of Brazil, in 2018, and the main characteristics of this mortality between 1996 and 2018 in the country. The study consists of two articulated phases: (i) bibliographical analysis of maternal mortality in Brazil; (ii) study in the Mortality Information System (SIM, in Portuguese). In 2018, from the 450 HRs, 159 showed a maternal mortality rate (MMR) of above 70 per 100,000 live births (LBs). Between 1996 and 2018, in Brazil, there was a reduction among women 30 to 49 years of age. However, in the age group of 10 to 29 years, there was no change during the time studied. The dissemination of the Maternal Mortality Committees, the PHPN, the PNAISM, and the "Stork Network" have all contributed to improvements in late pregnancies; however, they were inefficient at preventing deaths among young mothers. Compliance with SDG 3.1 requires: prioritization of CIR with MMR greater than 70.0/100,000 LB; qualification of prenatal services, focusing on care among women aged 10 to 29 years and hypertensive complications; and legalization of abortion.

Early neonatal mortality trend in adolescent pregnant women in the State of São Paulo, Brazil, from 1996 to 2017

BACKGROUND

The Infant mortality rate indicates the quality of life of a population. Infant mortality has two important components: neonatal mortality, divided into early and late and post-neonatal mortality. The more developed a country is and the greater its population's well-being, the greater the weight of the neonatal component on infant mortality. In addition several factors may determine or be associated with the occurrence of infant deaths including maternal age. The teenage pregnancy rates in Latin America and the Caribbean remain the second highest in the world, In Brazil, between 2010 and 2015, for every thousand adolescents between 15 and 19 years old, about 69 became pregnant and gave birth to their babies. Thus, the objective of this study is to evaluate the trend of Early Neonatal Mortality Rates in children of pregnant adolescents, which occurred in the period 1996-2017, in the state of São Paulo, Brazil, according to the maternal age group.

METHODS

This is an ecological study of time series using official mortality data obtained from the Mortality Information System and live birth data obtained from the Live Birth Information System. Deaths of newborns aged between zero and six complete days were collected by place of residence. The trends in rates per 1,000 live births were calculated by Prais-Winsten regression, obtaining their annual percentage change (VPA) and the respective 95% confidence intervals, analyzed by age group. All analyzes were processed using the STATA 15.1 software.

RESULTS

In the state of São Paulo, between 1996 and 2017, 16,161 deaths were reported in children from zero to six days old and 2,320,584 live births in mothers aged 10-19 years, living in the state of São Paulo, Brazil. Of this total, it was observed that the early neonatal mortality rate decreased until the year 2005-2006, remained stationary after, and was higher in newborns of mothers aged 10-14 years (13.18 per 1,000) compared to mothers between 15-19 years (6.75 per 1,000).

CONCLUSIONS

In conclusion, although the early neonatal mortality rate showed a significant decreasing trend until approximately 2005, it remained stables after that.

Prevalence of dental caries in preschool children born preterm and/or with low birth weight: A systematic review with meta-analysis of prevalence data

The aim of the present systematic review and meta-analysis was to evaluate the prevalence of dental caries among preschool children who had been born preterm and/or with low birth weight (LBW) compared with those who had been born full term and/or with normal birth weight (NBW). Eight electronic databases were searched from interception up to November 2018 with no restrictions imposed regarding the date of publication or language. Two independent reviewers screened studies, extracted data, and assessed the risk of bias. A random-effects meta-analysis was run to pool the crude prevalence of dental caries according to gestational age and birth weight. We performed a narrative synthesis and assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Fifty-nine observational studies were included (55 in the meta-analysis). The prevalence of dental caries was 39% among preterm children, 30% among full-term children, 40% among LBW children, and 33% among NBW children (I² :97%-99%). The majority of studies reported that dental caries was not associated with gestational age or birth weight, with very low certainty of evidence. Preschool children born preterm or with LBW have similar dental caries experience as those born full term or with NBW, with very low certainty of evidence (PROSPERO #CDR42018118086).

Intimate partner violence during pregnancy and risk of fetal and neonatal death: a meta-analysis with socioeconomic context indicators

OBJECTIVE

The objective of the study was to summarize the results from observational studies examining the risk of fetal and neonatal death (perinatal death) as a function of the experience of intimate partner violence during pregnancy and examine the influence of socioeconomic context indicators on this association.

DATA SOURCES

Bibliographic searches were conducted in PubMed, EMBASE, CINAHL, and LILACS until March 2019.

STUDY ELIGIBILITY CRITERIA

We considered observational studies that provided data on the association between intimate partner violence during pregnancy and perinatal death.

STUDY APPRAISAL AND SYNTHESIS METHODS

Information collected included study characteristics, type, and prevalence of intimate partner violence and the reported association between intimate partner violence and perinatal death. Quality of the included studies was assessed using the Newcastle-Ottawa scale. Two reviewers independently conducted all review procedures; disagreements were resolved by a third reviewer. Meta-analyses were conducted based on the specific type of intimate partner violence (physical, psychological, sexual, unspecified) and also based on any type of intimate partner violence, considering 1 effect size per study, regardless of the type of intimate partner violence analyzed. Meta-regression analyses were performed to assess the possible effects of socioeconomic context. The proportion of deaths attributable to the exposure of intimate partner violence based on the crude data from the 3 cohort studies available also was calculated.

RESULTS

Seventeen studies were included. The random-effects model showed a statistically significant increase in the odds of perinatal death among women exposed to unspecified intimate partner violence (odds ratio, 3.18; 95% confidence interval, 1.88-5.38), physical intimate partner violence (odds ratio, 2.46; 95% confidence interval, 1.76-3.44), and any type of intimate partner violence during pregnancy (odds ratio, 2.89; 95% confidence interval, 2.03-4.10). Meta-regression analysis showed stronger associations in countries with higher gross domestic product (odds ratio, 1.03; 95% confidence interval, 1.02-1.04) and a higher percentage of health expenditure (odds ratio, 1.27; 95% confidence interval, 1.09-1.46). The proportion of deaths attributable to exposure to intimate partner violence in cohort studies was attributable proportion, 60%; 95% confidence interval, 15-81%.

CONCLUSION

Pregnant women who experience intimate partner violence during pregnancy may be about 3 times more likely to suffer perinatal death compared with women who do not experience intimate partner violence. It should be a priority to include intimate partner violence screenings or other detection strategies in pregnancy monitoring or family-planning programs because these could help avoid preventable perinatal deaths.

Towards neonatal mortality risk classification: A data-driven approach using neonatal, maternal, and social factors

Infant mortality is an important health measure in a population as a crude indicator of the poverty and socioeconomic level. It also shows the availability and quality of health services and medical technology in a specific region. Although improvements have been observed in the last decades, the implementation of actions to reduce infant mortality is still a concern in many countries. To address such an important problem, this paper proposes a new support decision approach to classify newborns according to their neonatal mortality risk. Using features related to mother, newborn, and socio-demographic, we model the problem using a data-driven classification model able to provide the probability of a newborn dying until 28 t h days of life. More than a theoretical study, decision support tools as the one proposed here is relevant in countries in development as Brazil, because it aims at identifying risky neonates that may die to raise the attention of medical practitioners so that they can work harder to reduce the overall neonatal mortality. Overcoming an AUC of 96%, the proposed method is able to provide not just the probability of death risk but also an explicable interpretation of most important features for model decision, which is paramount in public health applications. Furthermore, we provide an extensive analysis across different rounds of experiments, including an analysis of pre and post partum features influence over data-driven model. Finally, different from previously conducted studies which rely on databases with less than 100,000 samples, our model takes advantage from a new proposed database, constructed using more than 1,400,000 samples comprising births and deaths extracted from public records in São Paulo-Brazil from 2012 to 2018.

Determinants of neonatal mortality in the largest international border of Brazil: a case-control study

BACKGROUND

Foz do Iguassu is a Brazilian municipality located in the most populous international border of the country and provides medical care to foreigners. Neonatal mortality in the city is higher than Brazil's average and corresponds to 61% of all deaths in children under five. The current study aimed to identify the determinants of neonatal mortality in Foz do Iguassu.

METHODS

In this case-control study, we analyzed all neonatal deaths occurred in Foz do Iguassu from 2012 to 2016. Birth and mortality data were extracted from two national governmental databases (SINASC and SIM). We extracted data on (i) maternal sociodemographic characteristics, (ii) pregnancy care, and (iii) newborn characteristics. Multiple logistic regression with the conceptual framework was applied to examine the factors associated with neonatal mortality.

RESULTS

Most of the deaths occurred in the early neonatal period (65.9%). The factors associated with neonatal death were fetal congenital anomaly (OR 22.49; CI 95% 7.44-67.95; p = < 0.001); low birth weight (OR 17.15; CI 95% 8.56-34.37; p = < 0.001), first minute Apgar score under 7 (OR 15.60; CI 95% 8.23-29.67; p = < 0.001); zero to 3 prenatal appointments (OR 3.34; CI 95% 1.28-8.73; p = 0.014) and prematurity (OR 3.60; CI 95% 1.87-7.11; p = < 0.001).

CONCLUSION

The high rate of neonatal death in Foz do Iguassu is strongly associated with newborn characteristics and not associated with maternal sociodemographic characteristics. Thus, the health services in the Brazilian side of this international borders should be aware of the quality of the prenatal care and childbirth attention provided.

Analysis of neonatal mortality risk factors in Brazil: a systematic review and meta-analysis of observational studies

OBJECTIVE

To identify, using a systematic review and meta-analysis of observational studies, which risk factors are significantly associated with neonatal mortality in Brazil, and to build a comprehensive national analysis on neonatal mortality.

SOURCES

This review included observational studies on neonatal mortality, performed between 2000 and 2018 in Brazilian cities. The MEDLINE, Elsevier, Cochrane, LILACS, SciELO, and OpenGrey databases were used. For the qualitative analysis, the Newcastle-Ottawa Scale was used. For the quantitative analysis, the natural logarithms of the risk measures and their confidence intervals were used, as well as the DerSimonian and Laird method as a random effects model, and the Mantel-Haenszel model for heterogeneity estimation. A confidence level of 95% was considered.

SUMMARY OF FINDINGS

The qualitative analysis resulted in six studies of low and four studies of intermediate-low bias risk. The following exposure factors were significant: absence of partner, maternal age ≥35 years, male gender, multiple gestation, inadequate and absent prenatal care, presence of complications during pregnancy, congenital malformation in the assessed pregnancy, Apgar<7 at the fifth minute, low and very low birth weight, gestational age≤37 weeks, and caesarean delivery.

CONCLUSION

The most significant risk factors presented in this study are modifiable, allowing aiming at a real reduction in neonatal deaths, which remain high in the country.

Fetal, neonatal, and post-neonatal mortality in the 2015 Pelotas (Brazil) birth cohort and associated factors

This study aimed to describe fetal, neonatal, and post-neonatal mortality and associated factors in participants of the 2015 Pelotas (Brazil) birth cohort. The child mortality sub-study followed up all deaths in the first year of life. Data were collected on intrauterine fetal deaths (weight ≥ 500g and/or gestational age ≥ 20 weeks), neonatal deaths (< 28 days of life), and post-neonatal deaths (from 28 days to the end of the first year of life). Descriptive analyses using the Pearson chi-square test and a multinomial logistic regression to estimate the risk of fetal, neonatal, and post-neonatal deaths compared to live infants in the cohort (reference group) were performed. Data from 4,329 eligible births were collected, of which 54 died during the fetal period. Of the 4,275 eligible live births, 59 died in the first year of life. An association between fetal, neonatal, and post-neonatal deaths (OR = 15.60, 7.63, and 5.51 respectively) was found, as well as less than six prenatal consultations. Compared to live infants, fetal deaths were more likely to occur in non-white mothers, and neonatal deaths were 14.09 times more likely to occur in a preterm gestational age (< 37 weeks). Compared to live infants, infants that were born in a C-section delivery had 3.71 increased odds of post-neonatal death. Additionally, neonatal deaths were 102.37 times more likely to have a low Apgar score on the fifth minute after birth. These findings show the need for early interventions during pregnancy, ensuring access to adequate prenatal care.

Determinants of perinatal mortality among cohorts of pregnant women in three districts of North Showa zone, Oromia Region, Ethiopia: Community based nested case control study

BACKGROUND

Statistics indicate that Ethiopia has made remarkable progress in reducing child mortality. It is however estimated that there is high rate of perinatal mortality although there is scarcity of data due to a lack of vital registration in the country. This study was conducted with the purpose of assessing the determinants and causes of perinatal mortality among babies born from cohorts of pregnant women in three selected districts of North Showa Zone, Oromia Region, Ethiopia. The study used community based data, which is believed to provide more representative and reliable information and also aimed to narrow the data gap on perinatal mortality.

METHODS

A community based nested case control study was conducted among 4438 (cohorts of) pregnant women. The cohort was followed up between March 2011 to December 2012 in three districts of Oromia region, Ethiopia, until delivery. The World Health Organization verbal autopsy questionnaire for neonatal death was used to collect data. A binary logistic regression model was used to identify determinants of perinatal mortality. Causes of deaths were assigned by a pediatrician and neonatologist. Cases are stillbirths and early neonatal death. Control are live births surviving of the perinatal period' RESULT: A total of 219 newborns (73 cases and 146 controls) were included in the analysis. Perinatal mortality rate was 16.5 per 1000 births. Mothers aged 35 years and above had a higher risk of losing their newborn babies to perinatal deaths than younger mothers [AOR 7.59, (95% CI, 1.91-30.10)]. Babies born to mothers who had a history of neonatal deaths were also more likely to die during the perinatal period than their counterparts [AOR 5.42, (95% CI, 2.27-12.96)]. Preterm births had a higher risk of perinatal death than term babies [AOR 8.58, (95% CI, 2.27-32.38)]. Similarly, male babies were at higher risk than female babies [AOR 5.47, (95% CI, 2.50-11.99)]. Multiple birth babies had a higher chance of dying within the perinatal period than single births [AOR 3.59, (95% CI, 1.20-10.79)]. Home delivery [AOR 0.23, (95% CI, 0.08-0.67)] was found to reduce perinatal deaths. Asphyxia, sepsis and chorioamnionitis were among the leading causes of perinatal deaths.

CONCLUSION

This study reported a lower perinatal mortality rate. The main causes of perinatal death identified were often related to maternal factors. There is still a need for greater focus on these interrelated issues for further intervention.

Access to and use of health services as factors associated with neonatal mortality in the North, Northeast, and Vale do Jequitinhonha regions, Brazil

OBJECTIVE

To analyze the factors associated with neonatal mortality related to health services accessibility and use.

METHODS

Case-control study of live births in 2008 in small- and medium-sized municipalities in the North, Northeast, and Vale do Jequitinhonha regions, Brazil. A probabilistic sample stratified by region, population size, and information adequacy was generated for the choice of municipalities. Of these, all municipalities with 20,000 inhabitants or less were included in the study (36 municipalities), whereas the remainder were selected according to the probability method proportional to population size, totaling 20 cities with 20,001-50,000 inhabitants and 19 municipalities with 50,001-200,000 inhabitants. All deaths of live births in these cities were included. Controls were randomly sampled, considered as four times the number of cases. The sample size comprised 412 cases and 1772 controls. Hierarchical multiple logistic regression was used for data analysis.

RESULTS

The risk factors for neonatal death were socioeconomic class D and E (OR=1.28), history of child death (OR=1.74), high-risk pregnancy (OR=4.03), peregrination in antepartum (OR=1.46), lack of prenatal care (OR=2.81), absence of professional for the monitoring of labor (OR=3.34), excessive time waiting for delivery (OR=1.97), borderline preterm birth (OR=4.09) and malformation (OR=13.66).

CONCLUSION

These results suggest multiple causes of neonatal mortality, as well as the need to improve access to good quality maternal-child health care services in the assessed places of study.

[Hospitalizations due to complications of pregnancy and maternal and perinatal outcomes in a cohort of pregnant women in the Brazilian Unified National Health System in São Paulo, Brazil]

Maternal morbidity, fetal mortality, and neonatal mortality are important indicators of maternal and child health. The study aimed to describe maternal and perinatal outcomes (low birth weight, prematurity, fetal and neonatal deaths, postpartum hospitalizations, and readmission of newborns) in a cohort of pregnant women whose deliveries were covered by the Brazilian Unified National Health System (SUS) in the city of São Paulo, Brazil, in the second semester of 2012. We obtained a retrospective cohort of 55,404 pregnant women with deterministic and probabilistic linkage of data from the Hospital Information System of the SUS (SIH/SUS), Information System on Live Births (SINASC), Mortality Information System (SIM), and National Registry of Health Establishments (CNES) databases. Hospitalizations due to obstetric complications occurred in 4.3% of the women. The most frequent diagnoses were infection, hypertensive disease of pregnancy, and diabetes. Hospitalizations prior to childbirth were more common in pregnant women 35 years or older and those with a history of multiple pregnancies and low schooling. Postpartum hospitalizations were three times greater and maternal mortality was nine times greater in pregnant women with a history of previous hospitalization due to obstetric complications. Adverse perinatal outcomes (fetal and neonatal mortality and low birth weight) were twice as frequent in infants of women with previous hospitalization when compared to those without. A similar pattern was seen in hospitalization of newborns soon after birth and in hospital readmission. Adverse maternal and perinatal outcomes were more frequent in pregnant women with a history of previous hospitalization.

[Risk factors associated with the development of perinatal asphyxia in neonates at the Hospital Universitario del Valle, Cali, Colombia, 2010-2011]

INTRODUCTION

Perinatal asphyxia is one of the main causes of perinatal mortality and morbidity worldwide and it generates high costs for health systems; however, it has modifiable risk factors.

OBJECTIVE

To identify the risk factors associated with the development of perinatal asphyxia in newborns at Hospital Universitario del Valle, Cali, Colombia.

MATERIALS AND METHODS

Incident cases and concurrent controls were examined. Cases were defined as newborns with moderate to severe perinatal asphyxia who were older than or equal to 36 weeks of gestational age, needed advanced resuscitation and presented one of the following: early neurological disorders, multi-organ commitment or a sentinel event. The controls were newborns without asphyxia who were born one week apart from the case at the most and had a comparable gestational age. Patients with major congenital malformations and syndromes were excluded.

RESULTS

Fifty-six cases and 168 controls were examined. Premature placental abruption (OR=41.09; 95%CI: 4.61-366.56), labor with a prolonged expulsive phase (OR=31.76; 95%CI: 8.33-121.19), lack of oxytocin use (OR=2.57; 95% CI: 1.08 - 6.13) and mothers without a partner (OR=2.56; 95% CI: 1.21-5.41) were risk factors for the development of perinatal asphyxia in the study population. Social difficulties were found in a greater proportion among the mothers of cases.

CONCLUSIONS

Proper control and monitoring of labor, development of a thorough partograph, and active searches are recommended to ensure that all pregnant women have adequate prenatal care with the provision of social support to reduce the frequency and negative impact of perinatal asphyxia.

Determinants of infant mortality in the Jequitinhonha Valley and in the North and Northeast regions of Brazil

OBJECTIVE

This study aims to identify the social and demographic determinants, in addition to the determinants of reproductive health and use of health services, associated with infant mortality in small and medium-sized cities of the North, Northeast and Southeast regions of Brazil.

METHODS

This is a case-control study with 803 cases of death of children under one year and 1,969 live births (controls), whose mothers lived in the selected cities in 2008. The lists of the names of cases and controls were extracted from the Sistema de Informação sobre Mortalidade (SIM - Mortality Information System) and the Sistema de Informação sobre Nascidos Vivos (SINASC - Live Birth Information System) and supplemented by data obtained by the research of "active search of death and birth". Data was collected in the household using a semi-structured questionnaire, and the analysis was carried out using multiple logistic regression.

RESULTS

The final model indicates that the following items are positively and significantly associated with infant mortality: family working in agriculture, mother having a history of fetal and infant losses, no prenatal or inadequate prenatal, and not being associated to the maternity hospital during the prenatal period. We have observed significant interactions to explain the occurrence of infant mortality between race and socioeconomic score and between high-risk pregnancy and pilgrimage for childbirth.

CONCLUSIONS

The excessive number of home deliveries and pilgrimage for childbirth indicates flaws in the line of maternity care and a lack of collaboration between the levels of outpatient and hospital care. The study reinforces the need for an integrated management of the health care networks, leveraging the capabilities of cities in meeting the needs of pregnancy, delivery and birth with quality.

OBJETIVO

Identificar os determinantes sociais, demográficos, da saúde reprodutiva e de utilização dos serviços de saúde associados ao óbito infantil em municípios de pequeno e médio porte das regiões Norte, Nordeste e Sudeste do Brasil.

MÉTODOS

Trata-se de um estudo caso-controle com 803 casos de óbito de menores de um ano e 1.969 nascidos vivos (controles), cujas mães residiam em 2008 nos municípios selecionados. As listas nominais dos casos e do controles foram extraídas do Sistema de Informação sobre Mortalidade e do Sistema de Informação sobre Nascidos Vivos e completadas por dados obtidos pela pesquisa de "busca ativa de óbito e nascimento". A coleta de dados foi realizada em domicílio por meio de questionário semiestruturado, e a análise, por meio de regressão logística múltipla.

RESULTADOS

O modelo final indicou que estão associadas positivamente e significativamente ao óbito infantil: a família trabalhar na agricultura, a mãe ter tido história de perdas fetais e infantis, não ter feito pré-natal ou ter tido um pré-natal inadequado e não estar vinculada à maternidade durante o pré-natal. Foram observadas interações significativas para explicar a ocorrência do óbito infantil entre cor de pele e escore socioeconômico e entre gestação classificada como de risco e peregrinação para o parto.

CONCLUSÕES

O número excessivo de partos domiciliares e de peregrinação para o parto indica falhas na linha de cuidado da gestante e desarticulação entre os níveis de atenção ambulatorial e hospitalar. O estudo reforça a necessidade de uma gestão integrada das redes de atenção à saúde, potencializando as capacidades municipais em atender, com qualidade, à gestação, ao parto e ao nascimento.

[Spatial analysis of neonatal mortality in the state of São Paulo, 2006-2010]

OBJECTIVE

The aim of this study was to identify spatial patterns of distribution of overall, early, and late neonatal mortality rates in São Paulo state.

METHODS

An ecological and exploratory study was carried in micro-regions of São Paulo sate. Mortality rates per 1,000 live births (LB) were calculated using data on overall, early, and late neonatal mortality in São Paulo between 2006 and 2010; these data were obtained from Information System and Information Technology Department of the Brazilian National Healthcare System (DATASUS). The global Moran's indices (I) were calculated for rates and thematic maps were built with these rates. Micro-regions with a high priority for intervention were identified by the box map. The software TerraView 4.2.1 was used for spatial analysis.

RESULTS

The rates of early and late neonatal mortality were 6.2 per thousand LB and 2.5 per thousand LB, respectively. The global Moran's indexes (I) were I=0.13, I=0.15, and I=0.26 for overall, early, and late neonatal mortality rates, respectively; all global Moran's indices showed p-values <0.05. Thematic maps showed clusters of micro-regions with high rates located in the southwest and east of the state.

CONCLUSION

The results presented in this study allow the implementation of policies by health managers, aiming to reduce neonatal mortality.

Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012

BACKGROUND

Maternal near-miss (MNM) audits are considered a useful approach to improving maternal healthcare. The aim of this study was to evaluate the factors associated with maternal near-miss cases in childbirth and the postpartum period in Brazil.

METHODS

The study is based on data from a nationwide hospital-based survey of 23,894 women conducted in 2011-2012. The data are from interviews with mothers during the postpartum period and from hospital medical files. Univariate and multivariable logistic regressions were performed to analyze factors associated with MNM, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals (95 % CI).

RESULTS

The estimated incidence of MNM was 10.2/1,000 live births (95 % CI: 7.5-13.7). In the adjusted analyses, MNM was associated with the absence of antenatal care (OR: 4.65; 95 % CI: 1.51-14.31), search for two or more services before admission to delivery care (OR: 4.49; 95 % CI: 2.12-9.52), obstetric complications (OR: 9.29; 95 % CI: 6.69-12.90), and type of birth: elective C-section (OR: 2.54; 95 % CI: 1.67-3.88) and forceps (OR: 9.37; 95 % CI: 4.01-21.91). Social and demographic maternal characteristics were not associated with MNM, although women who self-reported as white and women with higher schooling had better access to antenatal and maternity care services.

CONCLUSION

The high proportion of elective C-sections performed among women in better social and economic situations in Brazil is likely attenuating the benefits that could be realized from improved prenatal care and greater access to maternity services. Strategies for reducing the rate of MNM in Brazil should focus on: 1) increasing access to prenatal care and delivery care, particularly among women who are at greater social and economic risk and 2) reducing the rate of elective cesarean section, particularly among women who receive services at private maternity facilities, where C-section rates reach 90 % of births.

Disparities and barriers encountered by immigrant Dominican mothers accessing prenatal care services in Puerto Rico

Inadequate access to prenatal services has been associated with higher rates of mother and child mortality and premature births in the general population. Thus, this paper aims to compare the utilization and adequacy of prenatal care services of Dominican immigrant mothers with that of Puerto Rican mothers. Data was extracted from birth certificates using a cohort from 1998 to 2002 (n = 252, 919). The Kotelchuck index for adequate prenatal care was used for comparison with socio-demographic characteristics of the population. Less than half of Dominican mothers (48.5 %) received adequate prenatal care compared to more than two-thirds (69.1 %) of Puerto Rican mothers (p < .001). After controlling for demographic characteristics, health insurance, pregnancy risks, complications and previous birth (parity) the odds of receiving adequate care of Dominican mothers was 0.7 that of Puerto Rican mothers (p < .001). These results suggest significant disparities in obtaining adequate prenatal care services among migrant women and native Puerto Ricans.

[Factors associated with neurodevelopment in children 6-18 months of age in public daycare centers in João Pessoa, Paraíba State, Brazil]

This study aimed to determine the prevalence of altered neurodevelopment in children in public daycare centers in João Pessoa, Paraíba State, Brazil, and to analyze factors associated with child development. A cross-sectional study was conducted in a sample of children 6 to 18 months of age enrolled in daycare. Child development was assessed by the Denver II Screening Test. Biological, riables were studied with a questionnaire and form. Associations were adjusted using logistic regression. Altered development was present in 52.7% of the children and was associated with age > 12 months (OR = 4.3), vaginal delivery (OR = 4.4), neonatal phototherapy (OR = 7.9), and daycare centers not supported by the Family Health Strategy (OR = 2.9). The findings suggest that child development reflects the family's conditions and the care received from educational and healthcare services.

Factors associated with lack of prenatal care in a large municipality

OBJECTIVE To analyze the factors associated with a lack of prenatal care in a large municipality in southern Brazil. METHODS In this case-control age-matched study, 716 women were evaluated; of these, 179 did not receive prenatal care and 537 received prenatal care (controls). These women were identified using the Sistema Nacional de Informação sobre Nascidos Vivos (Live Birth Information System) of Pelotas, RS, Southern Brazil, between 2009 and 2010. Multivariate analysis was performed using conditional logistic regression to estimate the odds ratios (OR). RESULTS In the final model, the variables associated with a lack of prenatal care were the level of education, particularly when it was lesser than four years [OR 4.46; 95% confidence interval (CI) 1.92;10.36], being single (OR 3.61; 95%CI 1.85;7.04), and multiparity (OR 2.89; 95%CI 1.72;4.85). The prevalence of a lack of prenatal care among administrative regions varied between 0.7% and 3.9%. CONCLUSIONS The risk factors identified must be considered when planning actions for the inclusion of women in prenatal care by both the central management and healthcare teams. These indicated the municipal areas with greater deficits in prenatal care. The reorganization of the actions to identify women with risk factors in the community can be considered to be a starting point of this process. In addition, the integration of the activities of local programs that target the mother and child is essential to constantly identify pregnant women without prenatal care.

Atenção ao pré-natal e parto em mulheres usuárias do sistema público de saúde residentes na Amazônia Legal e no Nordeste, Brasil 2010

Objetivos: descrever a adequação da atenção à saúde entre as mulheres que fizeram o pré-natal e/ou parto no Sistema Único de Saúde (SUS), nos municípios prioritários para a redução da mortalidade infantil na Amazônia Legal e no Nordeste. Métodos: análise de dados secundários de inquérito de base populacional com mães e crianças menores de um ano de idade que compareceram à Campanha de vacinação em 2010. A amostra estudada foi de 13.205 mulheres com acompanhamento de pré-natal e de 13.044 mulheres com acompanhamento de parto, em 252 municípios prioritários. A adequação do pré-natal e parto foi classificada em conformidade com indicadores de processo propostos pelo Programa Nacional de Humanização do Pré-natal e Nascimento. Resultados: entre as mulheres investigadas 75,4% realizaram seis ou mais consultas de pré-natal, mas somente 3,4% tiveram acesso a um pré-natal classificado como adequado. O acesso à ultrassonografia foi relatado por 96,1% das mulheres, ao exame de HIV por 91,8% e ao teste de sífilis por 68,7%. Apenas 44,2% das mulheres recebeu indicação da maternidade na qual deveria fazer o parto e a internação no local indicado ocorreu em 8,6% dos casos. A atenção ao parto foi considerada adequada para apenas 1% das entrevistadas. Os resultados variaram entre os estados e níveis socioeconômicos das mulheres. Conclusões: foram identificadas falhas na atenção ao pré-natal e parto, que é inadequada e socialmente iníqua nestas regiões, contribuindo para os precários indicadores de saúde materno infantil na Amazônia Legal e no Nordeste do Brasil.

Perinatal factors associated with early neonatal deaths in very low birth weight preterm infants in Northeast Brazil

Background

In Brazil, the prevalence of prematurity has increased in recent years and it is a major cause of death in the neonatal period. Therefore, this study aims at assessing perinatal factors associated with early neonatal deaths in very low birth weight preterm infants born in a region of Brazil with low Human Development Index.

Methods

Prospective cohort study of inborns with gestational age 23^0/7-31^6/7 weeks and birthweight 500-1499 g without malformations in 19 public reference hospitals of the state capitals of Brazil’s Northeast Region. Perinatal variables associated with early neonatal death were determined by Cox regression analysis.

Result

Among 627 neonates, 179 (29%) died with 0–6 days after birth. Early death was associated to: absence of antenatal steroids (HR 1.59; 95% CI 1.11-2.27), multiple gestation (1.95; 1.28-3.00), male sex (2.01; 1.40-2.86), 5th minute Apgar <7 (2.93; 2.03-4.21), birthweight <1000 g (2.58; 1.70-3.88), gestational age <28 weeks (2.07; 1.42-3.02), use of surfactant (1.65; 1.04-2.59), and non-use of a pain scale (1.89; 1.24-2.89).

Conclusion

Biological variables and factors related to the quality of perinatal care were associated with the high chance of early death of preterm infants born in reference hospitals of Northeast Brazil.

[Intimate partner violence against pregnant women: study about the repercussions on the obstetric and neonatal results]

This observational, descriptive and analytic study aimed to identify the prevalence of IPV cases among pregnant women and classify them according to the type and frequency; identify the obstetric and neonatal results and their associations with the intimate partner violence (IPV) occurrence in the current pregnancy. It was developed with 232 pregnant women who had prenatal care at a public maternity hospital. Data were collected via structured interview and in the patients' charts and analyzed through the statistic software SAS® 9.0. Among the participants, 15.5% suffered IPV during pregnancy, among that 14.7% suffered psychological violence, 5.2% physical violence and 0.4% sexual violence. Women who did not desire the pregnancy had more chances of suffering IPV (p<0.00; OR=4.32 and 95% CI [1.77 - 10.54]). With regards to the obstetric and neonatal repercussions, there was no statistical association between the variables investigated. Thus, for the study participants there were no negative obstetric and neonatal repercussions related to IPV during pregnancy.

Baixo peso ao nascer em adolescentes e adultas jovens na Região Nordeste do Brasil

Objetivos: avaliar a associação entre as características sociodemográficas, do pré-natal e do parto de mães adolescentes e adultas jovens com o baixo peso ao nascer, em capitais e outros municípios da Região Nordeste do Brasil, no período de 2011 e 2012. Métodos: estudo transversal, de base hospitalar e nível regional, realizado em 2011 e 2012. As informações foram obtidas por meio de entrevista com a puérpera no pós-parto imediato e coletados dados dos prontuários maternos e dos recém-nascidos. Um modelo teórico conceitual foi estabelecido com três níveis de hierarquia e a variável dependente foi o baixo peso ao nascer (BPN). Resultados: do total de 3009 puérperas entrevistadas, 9,7% apresentaram conceptos com baixo peso. As puérperas que realizaram menos que seis consultas no pré-natal apresentaram uma chance 1,7 vezes maior de ter RN com baixo peso; ser primigesta aumentou a chance da ocorrência do BPN em 1,5 vezes; assim como a prematuridade que representou o principal fator de exposição, elevando em 21 vezes a chance desse desfecho. Conclusões: o estudo demonstrou alta frequência de baixo peso ao nascer entre mães adolescentes e adultas jovens, tendo como principais fatores associados o número insuficiente de consultas pré-natal, primigestação e prematuridade.

Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido

Estudo de coorte sobre a mortalidade neonatal na pesquisa Nascer no Brasil, com entrevista e avaliação de prontuários de 23.940 puérperas entre fevereiro de 2011 e outubro de 2012. Utilizou-se modelagem hierarquizada para análise dos potenciais fatores de risco para o óbito neonatal. A taxa de mortalidade foi 11,1 por mil; maior nas regiões Norte e Nordeste e nas classes sociais mais baixas. O baixo peso ao nascer, o risco gestacional e condições do recém-nascido foram os principais fatores associados ao óbito neonatal. A inadequação do pré-natal e da atenção ao parto indicaram qualidade não satisfatória da assistência. A peregrinação de gestantes para o parto e o nascimento de crianças com peso < 1.500g em hospital sem UTI neonatal demonstraram lacunas na organização da rede de saúde. Óbitos de recém-nascidos a termo por asfixia intraparto e por prematuridade tardia expressam a evitabilidade dos óbitos. A qualificação da atenção, em especial da assistência hospitalar ao parto se configura como foco prioritário para maiores avanços nas políticas públicas de redução das taxas e das desigualdades na mortalidade infantil no Brasil.

Fatores associados ao obito neonatal de recem-nascidos de alto risco: estudo multicentrico em Unidades Neonatais de Alto Risco no Nordeste brasileiro

Este estudo pretendeu determinar os fatores associados à mortalidade intra-hospitalar, utilizando como variáveis explicativas as características individuais da mãe, da assistência ao pré-natal, parto e período neonatal e dos recém-nascidos internados em Unidades Neonatais de Alto Risco (UTIN) integrantes da Rede Norte-Nordeste de Saúde Perinatal no Nordeste do Brasil. Foi realizado estudo longitudinal, multicêntrico de base hospitalar. A população do estudo compreendeu 3.623 nascidos vivos internados em 34 UTIN. Após o ajuste para os três níveis hierárquicos do modelo de determinação do óbito em UTIN até o 27 o dia de vida, associaram-se: tipo de parto – cesariana (OR = 0,72; IC95%: 0,56-0,95); não uso de corticoide antenatal (OR = 1,51; IC95%: 1,01-2,25); pré-eclâmpsia (OR = 0,73; IC95%: 0,56-0,95); oligodramnia (OR = 1,57; IC95%: 1,17-2,10); peso ao nascer < 2.500g (OR = 1,40; IC95%: 1,03-1,90); escore de Apgar 5 o minuto < 7 (OR = 2,63; IC95%: 2,21-3,14); uso de tubo endotraqueal (OR = 1,95; IC95%: 1,31-2,91); não uso de surfactante (OR = 0,54; IC95%: 0,43-0,69). O óbito em UTIN é determinado pelas condições assistenciais à gestação, parto e recém-nato.

[Validity and reliability of data and avoidability of the underlying cause of neonatal deaths in the intensive care unit of the North-Northeast Perinatal Care Network]

The aim of this study was to analyze the validity and reliability of data and the avoidability of neonatal deaths in the intensive care unit in the North-Northeast Perinatal Care Network (RENOSPE). The sample included 53 neonatal deaths recorded in the RENOSPE database that occurred in a maternity hospital in Teresina, Piauí State, Brazil. Validity was assessed by comparing causes recorded in the database with those from patient charts and calculating kappa index, sensitivity, and positive predictive value (PPV). Analysis of avoidability used the Brazilian List of Avoidable Deaths. When causes of death recorded in the RENOSPE database were compared with patient charts, kappa was 47.6% for maternal causes and 73.9% for congenital malformations, sensitivity was 95% and 83.3%, and PPV was 88.9% and 85.7%, respectively. The percentage of avoidable deaths in the RENOSPE database was high, attributable to lack of adequate prenatal care in 72% of cases. In conclusion, causes classified as congenital malformations were valid, and the high rate of avoidable deaths points to the need for improved prenatal care.

Risk factors for infant mortality in a municipality in southern Brazil: a comparison of two cohorts using hierarchical analysis

This study compared risk factors for infant mortality in 2000-2001 and 2007-2008 in Londrina, Paraná State, Brazil. Data on live births and infant deaths were linked in a single database, and a hierarchical regression model was used. Distal risk factors for infant mortality in 2000-2001 were maternal age < 20 or ≥ 35 years and lower maternal schooling. In 2007-2008, maternal age ≥ 35 or < 20 years were risk factors, while low schooling appeared as a protective factor. The following intermediate factors were associated with increased infant mortality in 2000-2001: multiple pregnancy, history of stillbirth, and insufficient number of prenatal visits, while cesarean delivery was a protective factor. Multiple pregnancy was the only intermediate risk factor in 2007-2008. All of the proximal factors were associated with higher infant mortality in 2000-2001, but only gestational age and 5-minute Apgar in 2007-2008. The risk factors for infant mortality changed from the first to the second cohort, which may be related to the expansion of social policies and primary care and changes in the reproductive and social patterns of Brazilian women.

Fatores determinantes da mortalidade neonatal em um município da Região Sul do Brasil

Pesquisa quantitativa do tipo ecológico cujo objetivo foi identificar os fatores de risco que determinaram o óbito neonatal no município de Londrina, Paraná, entre 2000 e 2009. Verificou-se que idade materna, escolaridade, renda familiar, ocupação, situação conjugal, tipo de parto e número de consultas pré-natais não se associaram ao óbito neonatal. Entretanto, o peso ao nascer, a idade gestacional, o índice de Apgar no 1º e 5º minutos e local do parto mostraram-se estatisticamente significativos. Mais de 73,0% dos recém-nascidos evoluíram para óbito no período neonatal precoce. A causa básica predominante foi a afecção perinatal (77,7%), sendo que 72,6% das mortes foram consideradas evitáveis e a maioria, reduzível por controle adequado da gravidez e do parto. Tais resultados reforçam a necessidade de investimentos na prevenção do parto prematuro com assistência antenatal e ao parto equitativa, acessível e integral entre os diferentes níveis de atenção à saúde materno-infantil.

Determinants of neonatal death with emphasis on health care during pregnancy, childbirth and reproductive history

OBJECTIVE

To identify risk factors for neonatal mortality, focusing on factors related to assistance care during the prenatal period, childbirth, and maternal reproductive history.

METHODS

This was a case-control study conducted in Maceió, Northeastern Brazil. The sample consisted of 136 cases and 272 controls selected from official Brazilian databases. The cases consisted of all infants who died before 28 days of life, selected from the Mortality Information System, and the controls were survivors during this period, selected from the Information System on Live Births, by random drawing among children born on the same date of the case. Household interviews were conducted with mothers.

RESULTS

The logistic regression analysis identified the following as determining factors for death in the neonatal period: mothers with a history of previous children who died in the first year of life (OR=3.08), hospitalization during pregnancy (OR=2.48), inadequate prenatal care (OR=2.49), lack of ultrasound examination during prenatal care (OR=3.89), transfer of the newborn to another unit after birth (OR=5.06), admittance of the newborn at the ICU (OR=5.00), and low birth weight (OR=2.57). Among the socioeconomic conditions, there was a greater chance for neonatal mortality in homes with fewer residents (OR=1.73) and with no children younger than five years (OR=10.10).

CONCLUSION

Several factors that were associated with neonatal mortality in this study may be due to inadequate care during the prenatal period and childbirth, and inadequate newborn care, all of which can be modified.

[Determinants of neonatal mortality: a case-control study in Fortaleza, Ceará State, Brazil]

This case-control study with 132 cases and 264 controls aimed to determine predictors of neonatal mortality using hierarchical modeling. Cases were defined as newborns that died within 28 days of birth, and controls as the survivors, among infants of mothers living in Fortaleza, Ceará State, Brazil. Hierarchical logistic regression identified factors associated with neonatal death: maternal race, with brown/black race showing a protective effect (OR = 0.23; IC95%: 0.09-0.56), time spent from home to the hospital > 30 minutes (OR = 3.12; 95%CI: 1.34-7.25), time < 1h or > 10 hours between hospital admission and delivery (OR = 2.43; 95%CI: 1.24-4.76), inadequate prenatal care (OR = 2.03; 95%CI: 1.03-3.99), low birth weight (OR = 14.75; 95%CI: 5.26-41.35), prematurity (OR = 3.41; 95%CI: 1.29-8.98), and male gender (OR = 2.09; 95%CI: 1.09-4.03). In this case series, neonatal deaths were associated with the quality of prenatal care and direct care during labor.

Risk factors of perinatal and neonatal mortality in Alexandria, Egypt

BACKGROUND

Egypt has already achieved the goal of reducing the under-five mortality rate (U5MR) by two-thirds. However, one of the challenges that Egypt currently faces is how to reduce the perinatal and neonatal mortality (PM, NM). This study aimed to identify the social and biomedical risk factors contributing toward PM and NM in Alexandria, Egypt.

PARTICIPANTS AND METHODS

A case-control design was used. Cases were 150 mothers whose index pregnancy terminated in perinatal (from the 28th week of pregnancy to less than 7 days after birth) and neonatal deaths (from the seventh day to less than the 28th day after birth). They were selected from the antenatal clinic and neonatal care unit of ElShatby University hospital for Obstetrics and gynecology. Controls were 150 mothers with live births ranging in age from 28 days up to 2 months selected from the outpatient clinics of ElShatby University Hospital for Pediatrics.

RESULTS

Stepwise logistic regression analysis indicated a higher risk of PM/NM among very young or very old mothers (OR=4.1 and 6.46, respectively), those who had previous PM/NM [odds ratio (OR)=12.7; 95% confidence interval (CI): 5.04-29.54], grand multiparous (OR=2.23; 95% CI: 1.50-5.42), those with infrequent antenatal visits (OR=3.88; 95% CI: 2.26-6.65), and mothers with complications during the index pregnancy (OR=9.21; 95% CI: 3.40-24.95).

CONCLUSION

This study confirms the evidence of a positive association between PM/NM and maternal age, obstetric history, and utilization of healthcare services. Appropriate age at marriage and pregnancy, spacing of and limiting the number of births, and improving antenatal, natal, and postnatal care are priority actions that can reduce PM/NM in Alexandria.

Infant mortality and prenatal care: contributions of the clinic in the light of Canguilhem and Foucault

This review study aimed to verify how studies conducted in Brazil have related infant mortality to prenatal care and to present contributions of the clinic in the light of Canguilhem and Foucault for qualification of the care. An integrative literature review was conducted from searches in the databases SciELO, LILACS, MEDLINE and BDENF for the period 2000 to 2009. The relationship between infant mortality and prenatal care is related to the insufficient number of consultations or to the quality of the care provided. Even when the number of and routine consultations in the prenatal care were adequate, avoidable deaths were present. For the qualification of prenatal care, it is suggested that the clinical knowledge and other elements that comprise the process of human living are considered, in order that the clinical view is enlarged and articulated to the technologies available in the health system and, together, they are able to contribute to the reduction of infant mortality in Brazil.

Prevalência de diarreia em crianças e condições de saneamento e moradia em áreas periurbanas de Guarulhos, SP

Foi realizado estudo transversal em área periurbana do Município de Guarulhos, SP, atendida pelo Programa Saúde da Família (PSF) para verificar associação entre ocorrência de diarreia em crianças de 0-2 anos de idade e características da criança, condições de saneamento e tipo de moradia. Os dados foram coletados nas fichas de registro do PSF. Foi realizada análise de regressão logística multivariada, a qual indicou a interação Moradia*Esgoto (outros materiais e ausência de rede de esgoto, p < 0,001) e idade (4 - 9 meses, p = 0,054; e 10 meses e mais, p = 0,008) como fatores de risco para ocorrência de diarreia. Em localidades com falta de dados para compor indicadores de saneamento básico que permitem identificar populações que vivem situações de risco para a ocorrência de diarréia, as informações coletadas pelo PSF podem se constituir em excelente ferramenta para identificação de núcleos populacionais com precárias condições de habitação e saneamento.

Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil

A persistência de desfechos perinatais negativos no Município do Rio de Janeiro, Brasil, sugere problemas na qualidade da assistência pré-natal. A última investigação realizada nessa cidade mostrou adequação de apenas 38% dessa assistência. O objetivo deste estudo é avaliar a adequação da assistência pré-natal na rede do SUS do Município do Rio de Janeiro. Foi realizado um estudo transversal, em 2007-2008, por meio de entrevistas com 2.422 gestantes em atendimento nos serviços de pré-natal de baixo risco. Para avaliação da adequação da assistência, foi utilizado o índice PHPN, com as recomendações do Programa de Humanização do Pré-natal e Nascimento, do Ministério da Saúde, e um índice PHPN ampliado, em que foram acrescentados procedimentos clinico-obstétricos, prescrição de sulfato ferroso suplementar e ações educativas. Foi encontrada adequação de 38,5% para o PHPN e 33,3% para o PHPN ampliado. Estratégias de ampliação da captação precoce das gestantes e melhor utilização dos contatos com os serviços para a realização de ações de atenção à saúde são prioritárias para a reversão desse quadro.

[Survival and risk factors for neonatal mortality in a cohort of very low birth weight infants in the southern region of São Paulo city, Brazil]

Population studies can help identify the complex set of risk factors for neonatal mortality among very low birth weight infants. A cohort (2000-2001) of 213 live newborns with birth weight < 1,500g in the southern region of São Paulo city, Brazil, was studied (112 neonatal deaths and 101 survivors). Data were obtained from home interviews and hospital records. Survival analysis and multiple Cox regression were performed. The high mortality in the delivery room and in the first day of life among neonates < 1,000g and < 28 weeks gestational age and the absence of survival in neonates < 700g suggest that care was actively oriented towards newborns with better prognosis. Increased risk of neonatal mortality was associated with maternal residence in slum areas, history of previous cesarean(s), history of induced abortion(s), adolescent motherhood, vaginal bleeding, and lack of prenatal care. Cesarean section and referral of the newborn to the hospital nursery showed protective effects. Birth weight less than 1,000g and Apgar index < 7 were associated with increased risk. The high mortality was due to poor living conditions and to maternal and neonatal characteristics. Improvement in prenatal and neonatal care could reduce neonatal mortality in these infants.

Desfechos relacionados à gravidez em áreas contaminadas, SP, Brasil

OBJETIVO: Estimar e comparar a prevalência dos eventos relacionados à gravidez (engravidar, baixo peso de nascimento, parto prematuro, aborto espontâneo, natimortalidade, malformações congênitas e gemelaridade) em populações exposta e não-exposta aos contaminantes ambientais na região do estuário de Santos e São Vicente. MÉTODOS: O estudo fez parte de um amplo projeto financiado pelo CNPq, que teve como objetivo estimar os efeitos à saúde associados à exposição aos contaminantes ambientais entre os moradores da Baixada Santista. O estudo transversal avaliou dois bairros do município de São Vicente, próximos a uma área contaminada, e um bairro no município de Bertioga, área controle. Para a obtenção dos dados foi aplicado um questionário estruturado e pré-testado em 236 domicílios em São Vicente e 251 domicílios em Bertioga. Para avaliar associações entre a área e as variáveis qualitativas utilizouse o teste qui-quadrado ou teste exato de Fisher; para avaliar as diferenças entre as variáveis, o teste t de Student ou o teste de comparação de duas proporções, e adotado nível de significância de 5%. RESULTADOS: Houve associação significativa entre morar em Bertioga (p = 0,01) e o número de gestações ocorridas nos últimos cinco anos. Em São Vicente, 64 (28,3%) mulheres em idade fértil engravidaram, enquanto em Bertioga foram 109 (38,8%). Não houve associações estatísticas significativas nas áreas com os demais desfechos da gravidez avaliados. CONCLUSÕES: As prevalências e as razões de chances prevalentes de baixo peso ao nascer, nascimentos prematuros e abortos espontâneos foram maiores nas áreas contaminadas, sem associações significativas. A evidência do estudo de diminuição do número de gestações na área contaminada reforça a necessidade de aprofundamento de estudos na região do estuário de Santos e São Vicente.

Fatores de risco para baixo peso ao nascer em maternidades públicas: um estudo transversal

O baixo peso ao nascer é apontado como o fator de maior influência na determinação da morbimortalidade neonatal, podendo estar associado a baixos níveis de desenvolvimento socioeconômico e de assistência materno-infantil. Trata-se de uma pesquisa quantitativa que objetivou descrever os fatores de risco para baixo peso ao nascimento de recém nascidos nas maternidades públicas do município de Santa Maria, Rio Grande do Sul. Os dados quantitativos foram submetidos à análise estatística descritiva. Os resultados apontaram como principais fatores de risco a prematuridade, a renda familiar inferior a dois salários mínimos, a nuliparidade e a multiparidade, a ocorrência de aborto prévio, o parto cirúrgico, as infecções, a pré-eclâmpsia e a história prévia de outros filhos de baixo peso. Recomenda-se o investimento na qualificação da assistência pré-natal, visto que muitos destes fatores de risco podem ser evitados ou minimizados por meio de uma atenção pré-natal de qualidade.

[Teenage pregnancy and other risk factors for fetal and infant mortality in the city of Rio de Janeiro, Brazil]

This article analyzes teenage pregnancy and other risk factors for fetal and infant mortality in the city of Rio de Janeiro, Brazil. The study included a sample of births in Rio de Janeiro, and exposure variables were organized hierarchically. For fetal death, the results showed the protective effect of adequate prenatal care, while maternal morbidity increased the risk. For neonatal death, adequate prenatal care and female gender in the newborn were protective factors, while black or brown maternal skin color, history of stillbirth, maternal morbidity, and physical aggression during the index pregnancy increased the risk. Low birth weight and prematurity were corroborated as determinants of fetal and neonatal death. Risk of post-neonatal death was highest with increased parity, intra-gestational morbidity, and low birth weight. Teenage pregnancy itself was an independent factor for post-neonatal death. The findings reaffirm the relevance of social and health policies targeting adolescents, as well as improvements in prenatal care.

[Avoidable causes of infant mortality in Brazil, 1997-2006: contributions to performance evaluation of the Unified National Health System]

Infant deaths were classified as avoidable, non-avoidable, and resulting from ill-defined conditions, from 1997 to 2006, using the Brazilian List of Avoidable Causes of Mortality. Non-linear regression was used to calculate trends in cause-specific infant mortality rates. There was a significant decline in both avoidable deaths and deaths from ill-defined causes (p < 0.001). Avoidable deaths decreased by 37% overall. Mortality avoidable through adequate intrapartum care and adequate neonatal care decreased by 27.7% and 42.5%, respectively, while mortality avoidable through adequate prenatal care increased by 28.3%. In conclusion, health services contributed to the reduction in infant mortality. The decrease in ill-defined causes of death indicates expanded access to health services. The increase in access to intrapartum and neonatal care contributed to the reduction in infant deaths. The increase in mortality avoidable through adequate prenatal care indicates the need for improvement in prenatal care.

[Early neonatal mortality according to level of hospital complexity in Greater Metropolitan São Paulo, Brazil]

The aim of this study was to analyze the profile of newborns, mothers, and early neonatal mortality according to the hospital's complexity and affiliation (or lack thereof) with the Unified National Health System (SUS) in Greater Metropolitan São Paulo, Brazil. The study was based on data for live births, deaths, and hospital registries. Factor and cluster analysis were used to obtain the typology of hospital complexity and user profile. The SUS treats more high-risk newborns and mothers with low schooling, insufficient prenatal care, and teenage mothers. The probability of early neonatal death was 5.6 live births (65% higher in the SUS), with no significant differences by level of hospital complexity, except those with extremely high (SUS) and medium (non-SUS) complexity. The difference in early neonatal mortality between the two systems was smaller in the group of newborns with birth weight < 1,500g (22%), but the rate was 131% higher in the SUS for newborns > 2,500g. There was a concentration of high-risk births in the SUS, but the difference in early neonatal mortality between SUS and non-SUS hospitals was smaller in this group of newborns. New studies are needed to elucidate the high mortality rate among newborns with birth weight > 2,500g in the SUS.

[Risk factors for pre-term birth in Londrina, Paraná State, Brazil]

The objective of this study was to identify risk factors associated with pre-term birth among live births in a hospital in Londrina, Paraná State, Brazil. Cases consisted of 328 pre-term births, and controls were 369 births with gestational age greater than 37 weeks. A multiple hierarchical logistic regression analysis was carried out. There was a significant correlation (p < 0.05) between pre-term birth and the following variables: socioeconomic status (slum residence); low age of head-of-family; maternal BMI < 19 or > 30 kg/m2; history of prematurity; history of assisted reproduction; mothers in a relationship for less than two years; maternal stress; weekly maternal alcohol consumption; insufficient prenatal care; gestational complications such as bleeding, genital tract infection, altered amniotic fluid volume, high blood pressure, and hospital admission; and twin pregnancy. Regular walks during pregnancy were a protective factor. Improved quality of prenatal care and the identification of the above factors during pregnancy may help reduce premature birth.

Traffic-related air pollution and perinatal mortality: a case-control study

BACKGROUND

Ambient levels of air pollution may affect the health of children, as indicated by studies of infant and perinatal mortality. Scientific evidence has also correlated low birth weight and preterm birth, which are important determinants of perinatal death, with air pollution. However, most of these studies used ambient concentrations measured at monitoring sites, which may not consider differential exposure to pollutants found at elevated concentrations near heavy-traffic roadways.

OBJECTIVES

Our goal was to examine the association between traffic-related pollution and perinatal mortality.

METHODS

We used the information collected for a case-control study conducted in 14 districts in the City of São Paulo, Brazil, regarding risk factors for perinatal deaths. We geocoded the residential addresses of cases (fetal and early neonatal deaths) and controls (children who survived the 28th day of life) and calculated a distance-weighted traffic density (DWTD) measure considering all roads contained in a buffer surrounding these homes.

RESULTS

Logistic regression revealed a gradient of increasing risk of early neonatal death with higher exposure to traffic-related air pollution. Mothers exposed to the highest quartile of the DWTD compared with those less exposed exhibited approximately 50% increased risk (adjusted odds ratio = 1.47; 95% confidence interval, 0.67-3.19). Associations for fetal mortality were less consistent.

CONCLUSIONS

These results suggest that motor vehicle exhaust exposures may be a risk factor for perinatal mortality.