Daniela Schoeps

Risk factors for early neonatal mortality

OBJECTIVE To assess risk factors for early neonatal mortality. METHODS A population-based case-control study was carried out with 146 early neonatal deaths and a sample of 313 controls obtained among survivals of the neonate period in the south region of the city of São Paulo, in the period of 8/1/2000 to 1/31/2001. Information was obtained through home interviews and hospital charts. Hierarchical assessment was performed in five groups with the following characteristics 1) socioeconomic conditions of mothers and families, 2) maternal psychosocial conditions, 3) obstetrical history and biological characteristics of mothers, 4) delivery conditions, 5) conditions of newborns RESULTS Risk factors for early neonate mortality were: Group 1: poor education of household head (OR=1.6; 95% CI: 1.1;2.6), household located in a slum area (OR=2.0; 95% CI: 1.2;3.5) with up to one room (OR=2.2; 95% CI: 1.1;4.2); Group 2: mothers in recent union (OR=2.0; 95% CI: 1.0;4.2), unmarried mothers (OR=1.8; 95% CI: 1.1;3.0), and presence of domestic violence (OR=2.7; 95% CI: 1;6.5); Group 3: presence of complications in pregnancy (OR=8.2; 95% CI: 5.0;13.5), previous low birth weight (OR=2.4; 95% CI: 1.2;4.5), absence of pre-natal care (OR=16.1; 95% CI: 4.7;55.4), and inadequate pre-natal care (block 3) (OR=2.1; 95% CI: 2.0;3.5); Group 4: presence of clinical problems during delivery (OR=2.9; 95% CI: 1.4;5.1), mothers who went to hospital in ambulances (OR=3.8; 95% CI: 1.4;10.7); Group 5: low birth weight (OR=17.3; 95% CI: 8.4;35.6) and preterm live births (OR=8.8; 95% CI: 4.3;17.8). CONCLUSIONS Additionally to proximal factors (low birth weight, preterm gestations, labor complications and unfavorable clinical conditions in gestation), the variables expressing social exclusion and presence of psychosocial factors were also identified. This context may affect the development of gestation and hinder the access of women to health services. Adequate prenatal care could minimize the effect of these variables.

Validation of birth certificates based on data from a case-control study

The information recorded on birth certificates was validated with data from a perinatal mortality case-control study, obtained from home interviews of mothers and hospital records for cases (early neonatal deaths) and controls. Sensitivity, specificity, and concordance were calculated for all variables and their estimated and real prevalence. The completeness of birth certificates was lowest for mothers parity and presence of congenital anomalies (records without information range from 23% to 31% for cases and controls). Birth certificates correctly identified low birth weight and type of delivery for cases and controls. Birth certificates showed high sensitivity and specificity to detect preterm births within cases. The number of preterm births was underestimated at 30.8% of the controls and 2.9% of the cases. Low maternal education was two times greater on birth certificates than in the mothers interview, for cases and controls. Completeness of birth certificates was higher in controls, but data quality was better in cases.

Risk-factors for antepartum fetal deaths in the city of São Paulo, Brazil

OBJECTIVE To assess risk factors for antepartum fetal deaths. METHODS A population-based case-control study was carried out in the city of São Paulo from August 2000 to January 2001. Subjects were selected from a birth cohort from a linked birth and death certificate database. Cases were 164 antepartum fetal deaths and controls were drawn from a random sample of 313 births surviving at least 28 days. Information was collected from birth and death certificates, hospital records and home interviews. A hierarchical conceptual framework guided the logistic regression analysis. RESULTS Statistically significant factors associated with antepartum fetal death were: mother without or recent marital union; mothers education under four years; mothers with previous low birth weight infant; mothers with hypertension, diabetes, bleeding during pregnancy; no or inadequate prenatal care; congenital malformation and intrauterine growth restriction. The highest population attributable fractions were for inadequacy of prenatal care (40%), hypertension (27%), intrauterine growth restriction (30%) and absence of a long-standing union (26%). CONCLUSIONS Proximal biological risk factors are most important in antepartum fetal deaths. However, distal factors - mothers low education and marital status - are also significant. Improving access to and quality of prenatal care could have a large impact on fetal mortality.

Qualidade das informações registradas nas declarações de óbito fetal em São Paulo, SP

OBJETIVO: Avaliar a qualidade da informacao registrada nas declaracoes de obito fetal. METODOS: Estudo documental com 710 obitos fetais em hospitais de Sao Paulo, SP, no primeiro semestre de 2008, registrados na base unificada de obitos da Fundacao Sistema Estadual de Analise de Dados e da Secretaria de Estado da Saude de Sao Paulo. Foi analisada a completitude das variaveis das declaracoes de obito fetal emitidas por hospitais e Servico de Verificacao de Obitos. Os registros das declaracoes de obito de uma amostra de 212 obitos fetais de hospitais do Sistema Unico de Saude foram comparados com os dados dos prontuarios e do registro do Servico de Verificacao de Obitos. RESULTADOS: Dentre as declaracoes de obito, 75% foram emitidas pelo Servico de Verificacao de Obitos, mais frequente nos hospitais do Sistema Unico de Saude (78%). A completitude das variaveis das declaracoes de obito emitidas pelos hospitais foi mais elevada e foi maior nos hospitais nao pertencentes ao Sistema Unico de Saude. Houve maior completitude, concordância e sensibilidade nas declaracoes de obito emitidas pelos hospitais. Houve baixa concordância e elevada especificidade para as variaveis relativas as caracteristicas maternas. Maior registro das variaveis sexo, peso ao nascer e duracao da gestacao foi observada nas declaracoes emitidas no Servico de Verificacao de Obitos. A autopsia nao resultou em aprimoramento da indicacao das causas de morte: a morte fetal nao especificada representou 65,7% e a hipoxia intrauterina, 24,3%, enquanto nas declaracoes emitidas pelos hospitais foi de 18,1% e 41,7%, respectivamente. CONCLUSOES: E necessario aprimorar a completitude e a indicacao das causas de morte dos obitos fetais. A elevada proporcao de autopsias nao melhorou a qualidade da informacao e a indicacao das causas de morte. A qualidade das informacoes geradas de autopsias depende do acesso as informacoes hospitalares.OBJECTIVE To evaluate the quality of information registered on fetal death certificates. METHODS Records were reviewed from 710 fetal deaths registered in the consolidated database of deaths from the State System for Data Analysis and the São Paulo State Secretary of Health, for deaths in São Paulo municipality (Southeastern Brazil) during the first semester of 2008. Completeness was analyzed for variables on fetal death certificates issued by hospitals and autopsy service. The death certificates from a sub-sample of 212 fetal deaths in hospitals of the National Unified Health System (public) were compared to medical records and to the records from Coroners Office. RESULTS Among death certificates, 75% were issues by Coroners Office, with a greater frequency in public hospitals (78%). Completeness of variables on death certificates issued by hospitals was higher among non-public hospitals. There was greater completeness, agreement and sensitivity in death certificates issued by hospitals. There was low agreement and high specificity for variables related to maternal characteristics. Increased reporting of gender, birth weight and gestational age was observed in certificates issued by Coroners Office. Autopsies did not result in improved ascertainment of cause of death, with 65.7% identified as unspecified fetal death as 24.3% as intrauterine hypoxia, while death certificates by hospitals reported 18.1% as unspecified and 41.7% as intrauterine hypoxia. CONCLUSIONS Completeness and the ascertainment of cause of fetal death need to be improved. The high proportion of autopsies did not improve information and ascertainment of cause of death. The quality of information generated by autopsies depends on access to hospital records.

Sobrevida e fatores de risco para mortalidade neonatal em uma coorte de nascidos vivos de muito baixo peso ao nascer, na Região Sul do Município de São Paulo, Brasil

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 Sao 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.

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 hospitals 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.

Maternal and neonatal characteristics and early neonatal mortality in Greater Metropolitan São Paulo, Brazil

The objective was to describe maternal and neonatal characteristics and early neonatal mortality rate according to place of delivery in Greater Metropolitan São Paulo, Brazil. The study linked the databases on live births and early neonatal deaths with the national hospital registry. Place of delivery was identified through certificates of live birth. There were a total of 154,676 live births: 98.7% in-hospital; 0.3% home deliveries, and 1% in other health services. Deliveries in birthing centers and small hospital units were associated with low obstetric risk and a low proportion of preterm and low birth weight infants, and as a result these services showed the lowest early neonatal mortality rate. Compared to hospital maternity ward deliveries, the early neonatal mortality rate was 4.7 times higher for home deliveries and 9.6 higher for emergency room deliveries. There is a high rate of hospital delivery care in São Paulo, but there is still a small portion of accidental home births and deliveries occurring in inappropriate health services, probably as a result of obstetric emergencies and difficulties in accessing hospital services.

Quality of information registered on fetal deaths certificates in São Paulo, Southeastern Brazil

OBJETIVO: Avaliar a qualidade da informacao registrada nas declaracoes de obito fetal. METODOS: Estudo documental com 710 obitos fetais em hospitais de Sao Paulo, SP, no primeiro semestre de 2008, registrados na base unificada de obitos da Fundacao Sistema Estadual de Analise de Dados e da Secretaria de Estado da Saude de Sao Paulo. Foi analisada a completitude das variaveis das declaracoes de obito fetal emitidas por hospitais e Servico de Verificacao de Obitos. Os registros das declaracoes de obito de uma amostra de 212 obitos fetais de hospitais do Sistema Unico de Saude foram comparados com os dados dos prontuarios e do registro do Servico de Verificacao de Obitos. RESULTADOS: Dentre as declaracoes de obito, 75% foram emitidas pelo Servico de Verificacao de Obitos, mais frequente nos hospitais do Sistema Unico de Saude (78%). A completitude das variaveis das declaracoes de obito emitidas pelos hospitais foi mais elevada e foi maior nos hospitais nao pertencentes ao Sistema Unico de Saude. Houve maior completitude, concordância e sensibilidade nas declaracoes de obito emitidas pelos hospitais. Houve baixa concordância e elevada especificidade para as variaveis relativas as caracteristicas maternas. Maior registro das variaveis sexo, peso ao nascer e duracao da gestacao foi observada nas declaracoes emitidas no Servico de Verificacao de Obitos. A autopsia nao resultou em aprimoramento da indicacao das causas de morte: a morte fetal nao especificada representou 65,7% e a hipoxia intrauterina, 24,3%, enquanto nas declaracoes emitidas pelos hospitais foi de 18,1% e 41,7%, respectivamente. CONCLUSOES: E necessario aprimorar a completitude e a indicacao das causas de morte dos obitos fetais. A elevada proporcao de autopsias nao melhorou a qualidade da informacao e a indicacao das causas de morte. A qualidade das informacoes geradas de autopsias depende do acesso as informacoes hospitalares.OBJECTIVE To evaluate the quality of information registered on fetal death certificates. METHODS Records were reviewed from 710 fetal deaths registered in the consolidated database of deaths from the State System for Data Analysis and the São Paulo State Secretary of Health, for deaths in São Paulo municipality (Southeastern Brazil) during the first semester of 2008. Completeness was analyzed for variables on fetal death certificates issued by hospitals and autopsy service. The death certificates from a sub-sample of 212 fetal deaths in hospitals of the National Unified Health System (public) were compared to medical records and to the records from Coroners Office. RESULTS Among death certificates, 75% were issues by Coroners Office, with a greater frequency in public hospitals (78%). Completeness of variables on death certificates issued by hospitals was higher among non-public hospitals. There was greater completeness, agreement and sensitivity in death certificates issued by hospitals. There was low agreement and high specificity for variables related to maternal characteristics. Increased reporting of gender, birth weight and gestational age was observed in certificates issued by Coroners Office. Autopsies did not result in improved ascertainment of cause of death, with 65.7% identified as unspecified fetal death as 24.3% as intrauterine hypoxia, while death certificates by hospitals reported 18.1% as unspecified and 41.7% as intrauterine hypoxia. CONCLUSIONS Completeness and the ascertainment of cause of fetal death need to be improved. The high proportion of autopsies did not improve information and ascertainment of cause of death. The quality of information generated by autopsies depends on access to hospital records.

SIM e SINASC: representação social de enfermeiros e profissionais de setores administrativos que atuam em hospitais no município de São Paulo

Few studies have analyzed the SINASC (Live Birth Information System) and MIS (Mortality Information System) applying qualitative methodology seeking to understand data production processes and contexts. This article aims to study the social representation of health professionals about Live Birth Certificates (LBC) and perinatal Death Certificates (DC). A total of 24 interviews were conducted with nurses and other professionals of 16 Unified Health System (SUS) and non-SUS hospitals of the city of Sao Paulo in 2009. Qualitative methodology was adopted along with the Collective Subject Discourse technique. Professionals acknowledged that they are an integral part of the information production process of SINASC and their reports indicate that they incorporate it in their work routine. They also perceive that training activities are a tool to understand the information produced by them and are aware of the utility of LBC information. Although physicians are legally responsible for the DC, other professionals frequently provide some of the information to complete it. The professionals see themselves as participants of the SINASC. Despite providing information to complete the DC, they do not see themselves as participants of the MIS operation.

Social representations of obstetricians and neonatologists about fetal and early neonatal death certificate in the city of São Paulo

INTRODUCTION The insatisfactory completeness of the variables in the Death Certificate (DC) makes it difficult to obtain specific perinatal mortality indicators. OBJECTIVE To assess the social representation of physicians about the perinatal DC. METHODS Twenty-five physicians were interviewed in 15 hospitals in the city of São Paulo, in 2009. Qualitative analysis was performed with the Collective Subject Discourse technique. RESULTS The DC is primarily considered according to its legal aspect. Physicians feel responsible for fulfilling the cause of death. The majority of them reported receiving help from other professionals to complete information on maternal characteristics and identification variables. There is lack of information on the mothers pre-natal conditions, which can make it difficult to identify the perinatal cause of death, mainly in the Unified Health System (SUS) hospitals. Some participants received specific DC training only when attending medical schools. CONCLUSIONS The organization of medical work may affect the completion of the DC, especially in hospitals from SUS. Other professionals contributed to this task and their training can improve the quality of information.