PERFIL DA MORTALIDADE NEONATAL COM ENFOQUE NA IDENTIFICAÇÃO DA EVITABILIDADE DOS ÓBITOS / PROFILE OF NEONATAL MORTALITY WITH A FOCUS ON IDENTIFYING THE AVOIDANCE OF DEATHS

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REPENF – Rev. Parana. Enferm. Jan-Dec 2020; 3(1): 20-29.

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SchapkoTR, Pereira SG, Higashi P, Souza IF.

Profile of neonatal mortality in Foz do Iguaçu, Paraná

PROFILE OF NEONATAL MORTALITY WITH A FOCUS ON IDENTIFYING THE AVOIDANCE OF DEATHS

PERFIL DA MORTALIDADE NEONATAL COM ENFOQUE NA IDENTIFICAÇÃO DA EVITABILIDADE DOS ÓBITOS PERFIL DE MORTALIDAD NEONATAL CON ENFOQUE EN LA IDENTIFICACIÓN DE LA EVITABILIDAD DE LAS MUERTES

Taís Regina Schapko1_{; Silviane Galvan Pereira}2_{; Priscilla Higashi}3_{; Isabel Fernandes de Souza}4 ABSTRACT

Objective: To identify the profile of neonatal mortality in Foz do Iguaçu/Paraná with a focus on identifying the avoidance of

deaths. Method: Descriptive research with a quantitative approach. The data collected by the Death Certificate of neonates, with death occurring in the municipality between 2014 and 2018. The sample consisted of 183 death records. Results: Most deaths were of male neonates, white skin color/race, extremely preterm, and with extremely low weight at birth. The gestation of a single fetus, the type of cesarean delivery, mothers without live children, without a history of fetal loss or abortion, aged between 20 and 34 years old, with completed high school and housewives predominated. Conclusion: The results indicate that the determinants that contributed most to neonatal mortality are in the proximal category, which includes biological factors such as the early neonatal period, prematurity, and low weight at birth. Deaths were considered avoidable and reducible by adequate control in pregnancy.

Descriptors: Maternal and Child Health; Infant Mortality; Infant, Newborn; Death. RESUMO

Objetivo: Identificar o perfil da mortalidade neonatal em Foz do Iguaçu/Paraná com enfoque na identificação da

evitabilidade dos óbitos. Método: Pesquisa descritiva, de abordagem quantitativa. Foram utilizados os dados coletados por meio da Declaração de Óbito de neonatos, com morte ocorrida no município, entre 2014 e 2018. A amostra foi composta por 183 registros de óbitos. Resultados: A maior parte dos óbitos era de neonatos do sexo masculino, da cor/raça branca, pré-termo extremo e com peso extremamente baixo ao nascer. Predominou a gestação de único feto, o tipo de parto cesáreo, as mães não possuíam filhos vivos, não tinham histórico de perda fetal ou aborto, eram da faixa etária entre 20 e 34 anos, possuíam ensino médio completo e eram donas de casa. Conclusão: Os resultados indicam que os determinantes que mais contribuíram para a mortalidade neonatal estão na categoria proximal, em que constam os fatores biológicos, tais como o período neonatal precoce, a prematuridade e o baixo peso ao nascer. As mortes foram consideradas evitáveis e redutíveis por adequado controle na gravidez.

Descritores: Saúde Materno-Infantil; Mortalidade Infantil; Recém-nascido; Morte. RESUMEN

Objetivo: Identificar el perfil de mortalidad neonatal en Foz do Iguaçu / Paraná (Brasil) con un enfoque en identificar

la evitabilidad de las muertes. Método: Investigación descriptiva, con abordaje cuantitativo. Se utilizaron los datos recogidos mediante Acta de Defunción de neonatos, con fallecimiento ocurrido en el municipio, entre 2014 y 2018. La muestra estuvo conformada por 183 registros de defunción. Resultados: La mayoría de las muertes fueron de recién nacidos varones, de color / raza blanca, extremadamente prematuros y con peso al nacer extremadamente bajo. Predominó la gestación de un solo feto, el tipo de parto por cesárea, las madres no tenían hijos vivos, no tenían antecedentes de pérdida fetal o aborto, tenían entre 20 y 34 años, habían terminado el bachillerato y eran amas de casa. Conclusión: Los resultados indican que los determinantes que más contribuyeron a la mortalidad neonatal se encuentran en la categoría proximal, que incluye factores biológicos, como el período neonatal temprano, la prematuridad y el bajo peso al nacer. Las muertes se consideraron prevenibles y reducibles mediante un control adecuado del embarazo.

Descriptores: Salud Materno Infantil; Mortalidad Infantil; Recién nacido; Muerte.

____________________

1_{Nurse. Master's student in Public Health in a Border Region by the State University of Western Paraná (Unioeste). E-mail:}

tais-regina.s@hotmail.com; ORCID:https://orcid.org/0000-0001-6813-437X

2 _{Nurse. Ph.D. in Sciences from the University of São Paulo (USP). Professor and internship supervisor in the nursing course at Centro} Universitário Uniamérica. E-mail: silviane@uniamerica.br; ORCID: https://orcid.org/0000-0002-8052-4204

3_{Nurse. Ph.D. in Public Health Nursing from the University of São Paulo (USP). Professor and internship supervisor in the nursing course at} Centro Universitário Uniamérica. E-mail: priscilla@uniamerica.br; ORCID: https://orcid.org/0000-0002-7048-8772

4_{Graduated in Computer Science. Ph.D. in Production Engineering from the Federal University of Rio de Janeiro (UFRJ). Professor of the Nursing} course at Centro Universitário Uniamérica. E-mail: ifsouza@yahoo.com.br; ORCID: https://orcid.org/0000-0002-6906-5756

Corresponding author: Silviane Galvan Pereira. Centro Universitário Uniamérica. Av. das Cataratas, 1118, Vila Yolanda, CEP 85853-000 – Foz do Iguaçu, PR, Brasil.

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SchapkoTR, Pereira SG, Higashi P, Souza IF. INTRODUCTION

Infant Mortality (IM) is a public health

problem worldwide(1)_{, a precursor to}

maternal and child health(2),_{and also an}

important indicator of the quality of the

health service offered to the population(3)_.

The low mortality rate shows positive actions in the health system such as monitoring fetal development, attention to pregnant women, early detection of health problems in the mother-child binomial, and other actions taken in the prenatal period. High rates are due to the difficulty of accessing health services and

inadequate health conditions(4)_.

Infant mortality is the death of a child from birth to 1 year old, classified as neonatal from 0 to 27 days old, and

post-neonatal from 28 days to one-year-old(5)_.

The neonatal period is the most

vulnerable one, registering most

deaths.(1,4,6)_{It is subdivided into early}

neonatal from 0 to 6 days old and late

neonatal from 7 to 27 days old(5)_{. The}

deaths of newborns as the object of interest in this research, with the highest percentage of about 70% of infant

deaths(3)_.

Despite that several regions of the world have a high infant mortality rate, neonatal deaths are higher in the African continent, where the risk of death in the first 28 days of life is approximately ten times higher than in a neonate living in a

developed country(7)_.

However, in recent years, there has been a reduction in the rate of IM worldwide, caused mainly by the decrease

in deaths in the post-neonatal period(8)_.

This decrease is due to the advance in the prevention and early treatment of infectious diseases that affected children

between 1 and 4 years old(9)_{. However,}

such advances have not occurred globally, with gaps in developing

countries(8)_{. In Brazil, although there are}

public policies aimed at reducing IM, the territorial extension with inequalities between regions represents a challenge

for Brazilian health services(10)_.

According to local specificities, each region has a different epidemiological

profile(4,11)_{. Characterizing the mortality}

profile is the initial step for establishing

and modifying health behaviors(8)_{. In}

Brazil, the Death Certificate (DC) is the instrument used to document the death. The Mortality Information System (MIS)

records information about the

circumstances of the death, according to the data contained in DC. After transcribing the data into the system, it is possible to know the general mortality

trends in the country(1,5)_.

In Brazil, child death surveillance is mandatory in public and private services that are part of the Unified Health System (SUS). The health service in which the

death occurred must forward the 1st_copy

of the DC to the municipal manager in charge of the MIS. Thus, the investigation of the death case begins until its closure. The responsibility for the investigation is always the child's municipality of

residence(5)_.

The factors that contribute to the increase in mortality can be classified as

proximal, intermediate, and distal

determinants(6,12-13)_{. The proximal set}

includes biological variables related to the newborn such as birth weight and duration of pregnancy. The determinants of care or intermediates are the care conditions in prenatal, delivery, and postpartum and the type of pregnancy, the type of delivery, and the mother's reproductive history. Finally, the distal

determinant represents the

socioeconomic factors that affect access to information and health services, such

as age and maternal education(4,12)_.

SUS still shows gaps in the continuity of maternal and child care that can impact the rate of prematurity and child morbidity and mortality in the country. These gaps are regional inequalities, geographical barriers, and access to

health services(14)_{. Therefore, we need to}

know the profile of death, the characteristics related to the mother, pregnancy, childbirth, the newborn, and the clinical information on the death of

each location(1,15)_{. Policies, programs, and}

strategies must be established according to the needs of each region so that

interventions are more effective(3,4)_.

Cross-border municipalities have similar characteristics and factors. Foz do Iguaçu (Paraná-Brazil) is one of the land borders with the largest flow of people in

the country(16)_{. Understanding the}

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Profile of neonatal mortality in Foz do Iguaçu, Paraná

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fundamental for its reduction, as it can improve the management of public health policies to ensure the optimization of assistance during the prenatal, delivery,

and puerperium(17)_.

Thus, this study aimed to identify the profile of neonatal mortality in Foz do Iguaçu (PR) with a focus on identifying the avoidance of deaths.

METHODS

This is descriptive research with a quantitative approach. We used data obtained from the epidemiological-surveillance sector collected via DC. Such data feeds the records in the MIS; however, the registration protocol has a flow with a delay of at least 12 months. Thus, to access the most recent municipal data, the researchers consulted local spreadsheets for the sector.

The municipality of Foz do Iguaçu (PR) is located in a triple border region with Paraguay and Argentina. The city has an obstetric center that is a regional reference for high-risk pregnancy and delivery and also for Brazilian pregnant women living in the neighboring

countries(18)_.

The evaluation of the cut of the variables of the sociodemographic profile and the maternal and child determinants of the declarations, we separated the records of the mortality of neonates aged 0 to 27 complete days, with the occurrence of death in the municipality of Foz do Iguaçu (Paraná) between January 2014 to December 2018. The sample was 183 death records collected in July 2019. For data analysis, Microsoft Office Excel® software was used and they were presented in tabular format, with absolute frequency and percentage of maternal and child determinants. The variables

were categorized considering the

proximal, intermediate, and distal

determinants. For each classification, specific tables were prepared with the items covered by each group.

The proximal category included the newborn's biological variables, such as age, gender, race, birth weight, and duration of pregnancy. The intermediate determinants were composed of the type

of pregnancy and delivery, the mother's reproductive history, the place of death, and whether there was medical assistance during death. In the distal determinant, variables related to age, education, and maternal occupation were grouped. The variables were categorized based on the criteria of the Ministry of Health.

The data obtained in a spreadsheet were coded according to the variables contained in DC. For the determinants, the maternal occupation was described according to the Brazilian Classification of Occupations (CBO). The cause of death was described by the International Statistical Classification of Diseases and Related Health Problems (ICD 10). The categorization of avoidance of deaths was performed after data collection through the avoidance classification of the Statewise System for Data Analysis Foundation (SEADE), which establishes whether the death was avoidable or not.

The Ethics Committee for Research with Human Beings (CEP) of the State University of Western Paraná approved the research, through opinion nº 3.359.584/2019, with Certificate of

Ethical Appreciation (CAAE) nº

13867619.3.0000.0107. The Informed Consent Term (ICF) was waived because is research with secondary data.

RESULTS

We collected the information from 183 neonatal death records living in the city of Foz do Iguaçu (PR). The highest occurrence of deaths was in 2014 with 23.50% (n = 43), with a decrease in 2015, 2016, and 2017, maintaining the same number of occurrences of this last year in 2018.

Regarding the proximal or biological determinants, the early neonatal period (0 - 6 days) recorded most of the deaths with 73.22% (n = 134), with an average of 5 days of life in the newborns, with a standard deviation of 6. Most deaths were male neonates 56.28% (n = 103) and white skin color/race 87.36% (n = 159). We also found that 43.89% (n = 79) of deaths were extremely preterm (less than 28 weeks), with a mean gestational age of 29.58 weeks, with a standard deviation

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of 6. Finally, 48.09% (n = 88) of the newborns had extremely low birth weight (less than 1000g), with an average of

1509g and a standard deviation of 1 (Table 01).

Table 01: Year of death and proximal/biological determinants of neonatal deaths in the period under study in Foz do Iguaçu, PR, 2019.

Variable Fi % Year of death (n=183) 2014 43 23.50 2015 42 22.95 2016 34 18.58 2017 32 17.49 2018 32 17.49 Age (n=183)

Early neonatal (0 to 6 days) 134 73.22

Late neonatal (7 to 27 days) 49 26.78

Gender (n=183) Male 103 56.28 Female 80 43.72 Race/skin color (n=182) White 159 87.36 Brown-skinned 23 12.64 Number of gestational weeks (n=180)

Extreme preterm (less than 28 weeks) 79 43.89

Very preterm (28 to 31 full weeks) 31 17.22

Moderate preterm (32 to 33 full weeks) 11 6.11

Late preterm (34 to 36 full weeks) 21 11.67

Full-term (37 to 41 weeks) 38 21.11

Weight at birth (n=183)

Extremely low weight (less than 1000g) 88 48.09

Very low weight (1000-1500g) 28 15.30

Low weight (1500-2500g) 25 13.66

Adequate weight (2500-4000g) 39 21.31

Overweight (4000g or more) 03 1.64

Source: The authors (2019).

Considering the intermediate or care

variables, single fetus gestation

predominated with 84.15% (n = 154) and the cesarean was the most recurrent type of delivery with 60.44% (n = 110) of the cases. The mothers did not have live children 32.60 (n = 59) and had no history of fetal loss or abortion 82.32 (n = 149). In 83.06% (n = 152) of the records, there was medical care during the death and in 15.30% (n = 28), the data field was not informed, shown as “ignored” data (Table 02).

Based on the distal or socio-demographic factors, we found that 65.57% (n = 120) were mothers between 20 and 34 years old, 38.33% (n = 69) had completed high school and 31.11 % (n = 56) had elementary school. Regarding the usual maternal occupation, we identified that 43.96% (n = 80) were housewives (Table 03).

According to the CID10 and SEADE classification, the deaths considered as avoidable were 80.87% (n = 148). They

were reducible for ‘an adequate

pregnancy control’ in 37.16% (n = 68) of the cases (Table 04).

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Table 02: Intermediate or care determinants of neonatal deaths in the period under study in Foz do Iguaçu, PR, 2019. Variable Fi % Type of Pregnancy (n=183) Only 154 84.15 Double 26 14.21 Triple or more 03 1.64 Type of Delivery (n=182) Vaginal 72 39.56 Cesarean 110 60.44 Number of children

born: Born alive (n=181) 0 59 32.60 1 56 30.94 2 32 17.68 3 or more 34 18.78 Number of children born: Fetal losses/abortions (n=181) 0 149 82.32 1 25 13.81 2 04 2.21 3 or more 03 1.66 Medical assistance during death (n=183) Yes 152 83.06 No 03 1.64 Ignored 28 15.30 Source: The authors (2019).

Table 03: Distal or socio-demographic determinants of neonatal deaths during the study period in Foz do Iguaçu, PR, 2019.

Variable Fi %

Maternal age (n=183)

Under 20 years old 30 16.39 Between 20 and 34 years old 120 65.57 35 years old or more 33 18.03

Mother´s Education level (n=180) No education level 05 2.78 Elementary school (1st_{to 4}th grade) 10 5.56 Elementary school (5th_{to 8}th grade) 56 31.11 High school 69 38.33

Incomplete higher education 16 8.89 Complete higher education 24 13.33

Usual maternal occupation (n=182) Housewife 80 43.96 Retail salesperson 12 6.59 Student 10 5.49 Housekeeper 10 5.49 Others 70 38.46

Source: The authors (2019).

Table 04: Avoidance of neonatal deaths according to the SEADE/ICD 10 classification in the period under study in Foz do Iguaçu, PR, 2019. Variable Fi % Cause of death (n=183) Avoidable 148 80.87 Non-avoidable 33 18.03 Poorly defined 02 1.10 Unclassified 00 0.00 Avoidable causes (n=148)

Reducible by adequate control in pregnancy 68 45.94

Fetus and NB* affected by hypertensive maternal disorders 16 10.81

Fetus and NB affected by multiple pregnancies 11 7.43

Extreme immaturity 09 6.08

Fetus and NB affected by premature rupture of membranes 07 4.73

Fetus and NB affected by cervical incompetence 06 4.05

Very low birth weight 04 2.70

Others 15 10.13

Reducible by adequate childbirth care 21 14.18

Fetus and NB affected by other forms of placental abruption and

hemorrhage 08 5.40

Fetus and NB affected by chorioamnionitis 04 2.70

Others 09 6.08

Reducible by prevention, diagnosis and early treatment

actions 37 25

Unspecified bacterial septicemia of the newborn 12 8.10

Necrotizing enterocolitis of fetus and newborn 06 4.05

Other transient electrolyte disturbances of the newborn 03 2.02

Others 16 10.81

Reducible through partnerships with other sectors 22 14.86

Unspecified heart malformation 03 2.02

Gastroschisis 03 2.02

Other specified congenital heart malformations 02 1.35

Others 14 9.45

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SchapkoTR, Pereira SG, Higashi P, Souza IF. DISCUSSION

The highest numbers of mortality in Foz do Iguaçu/PR were in 2014 and 2015. The proximal determinants include the biological factors about the mother and the newborn, considered as the direct

causes related to neonatal death(8,13)_{. The}

early neonatal period in the literature is responsible for the greater susceptibility

to infant mortality(1,4,6)_{, a result similar to}

this study. Since the first 24 hours of life are the most vulnerable and death in this period may be related to health care and

complications during pregnancy(1,4)_.

Males were predominant in neonatal

deaths(6,11,19)_{. Boys have a greater chance}

of developing respiratory problems, considering that they have delayed lung

maturation compared with females(1,11)

who have better metabolic adaptation and

faster lung maturation(4,6)_{. The white skin}

race was identified as the predominant in

infant deaths, similar to another study(11)_.

This is possible because, in the southern region of Brazil, there is a higher proportion of white people in the general population.

Prematurity is one of the most

predisposing factors to death(3-4)_and

most deaths were in newborns with less

than 28 gestational weeks(6.19)_,

considered as extremely preterm.

Gestational age is a factor related to death since it is linked to fetal development. If the birth occurs before 37 weeks of gestation, the neonate may

present morphological, functional

immaturity, and dysfunctions of organs

and systems(3)_.

NBs with low weight (LW) at birth are

the most susceptible to death(6)_{and can}

be considered as the main cause of

neonatal death(3,19)_{. LW may be related to}

delayed intrauterine growth(4)_{, maternal}

nutrition, smoking, infections, and/or inadequate prenatal care and may cause changes in the body such as metabolic

and cardiovascular dysfunction in

adulthood(3)_{. Extreme low weight is a}

factor that contributes to death(4)_{, and}

most deaths are registered in the range of 500-999g, as in other studies that raised the profile of mortality in this age

group(3-4)_.

The intermediate determinants are associated with care factors that include pre and perinatal care, the type of delivery, and maternal reproductive

history(13)_{. Cesarean delivery is described}

as an aggravating factor for death, as it can induce prematurity due to an error in calculating gestational age and the

appearance of respiratory morbidities(4,6)_.

The vaginal delivery is considered the most physiological and safe and a positive aspect is the adequate development of

the immune, cardiovascular, and

pulmonary system of the fetus(6)_.

However, some studies consider that the cesarean section is a protective factor in

high-risk pregnancies(1)_.

Maternal factors are considered risk

factors for neonatal deaths(4,6)_{. Single}

fetus pregnancy was predominant in

neonatal deaths as in other studies(4,6)_.

However, multiple pregnancies are a predisposing factor to death, as well as a

previous history of fetal loss(20)_{. Most}

mothers in this study had no history of live children and had no history of fetal loss or abortion.

The percentage of cesarean deliveries recommended by the World Health Organization (WHO) is up to 15% of total

deliveries. (21)_{However, Brazil has high}

rates as in this study with 60.44%. The cesarean delivery also has the potential for complications for mothers due to the increased consumption of medications,

longer hospitalization, and late

recovery(3)_.

The distal determinants are related to sociodemographic and socioeconomic factors that interfere with access to health and adequate assistance such as the level of understanding of the guidelines

provided by the health team(13)_.

Socioeconomic status and education are considered significant circumstances for

the reduction of infant mortality(22)_{. The}

rate of child deaths is twice as high among poor people than individuals with a higher

economic status(23)_.

The age group below 15 and over 35 years old is the interval considered at risk for pregnancy according to the Ministry of

Health(24)_{. In this study, we identified that}

the prevalent maternal age was 20 to 34

years old, similar to another study(4)_{. The}

interval identified in the study is considered to be the most fertile range

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and, therefore, represented the highest

number of deaths(6)_.

The mother´s education level is an indicator of socioeconomic status and is

associated with early mortality.(1,4)

However, when isolated, it is not a factor

that directly influences deaths(11)_{. The}

range identified in the study was 9 to 11 years of study, and another research also

showed similar results(6)_{. The level of}

education can interfere in the

understanding of the guidelines

performed by health professionals

regarding prevention and promotion

actions, hindering access to health(1)_.

Regarding maternal occupation, the study identified that the mothers of newborns who died were housewives. This is a discordant result in the literature, which states that women who work are more likely to present neonatal death, considering the time available for

self-care, prenatal self-care, and tests(4,6)_.

Deaths were considered avoidable according to the SEADE classification. This result was compatible with other studies that identified that most deaths

are avoidable(3-4)_{, most of them reducible}

by adequate control in pregnancy(10,12)_.

The reducible category for prevention, diagnosis, and early treatment actions is the second avoidable category with the highest number of deaths in the municipality under study.

As in other studies, the main cause of neonatal death was newborns affected by

hypertensive maternal disorders(25-26)_.

The other most prevalent causes were unspecified bacterial sepsis of the newborn, respiratory distress syndrome, NB affected by multiple pregnancies and

extreme immaturity. Prematurity,

infections, respiratory disorders, and

sepsis are considered the major causes of

neonatal mortality(3-4)_.

CONCLUSION

The profile of neonatal deaths in Foz do Iguaçu (PR) was composed of male NBs, white skin color/race, extremely preterm, and with extremely low weight at birth. The gestation of a single fetus, the type of cesarean delivery, mothers without live children, without a history of fetal loss or abortion, between 20 and 34 years old, with completed high school and housewives, predominated in the study. Deaths were considered avoidable and reducible by ‘a proper pregnancy control’, with the main cause of death when the NB is affected by maternal hypertensive disorders.

Such data, associated with the avoidance of deaths through care during pregnancy, suggest that there is a need to expand investment in primary care and to carry out actions that contribute to greater adherence to prenatal care practices, reducing neonatal mortality.

One of the limitations identified during the study was the information that was not in the source used for data collection, such as the beginning and number of consultations in prenatal care, the Apgar score, and the total number of live births in the municipality. This limited the findings because it was not possible to

identify the real incidence and

relationship of maternal and child determinants in neonatal mortality. Thus, we suggest that future investigations in

this area of knowledge address,

especially, the adherence of women and the quality of prenatal care offered in the municipality under study.

Individual author´s contributions: Schanko TR and Pereira SG: participated in the design and writing of

the project; data collection, analysis, and interpretation; writing of the article and final approval of the version to be published. Higashi P and Souza IF: participated in the relevant critical review of the intellectual content and final approval of the version to be published. All authors declared to be responsible for all aspects of the work, ensuring its accuracy and integrity.

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