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Epidemiologia e Serviços de Saúde

versión impresa ISSN 1679-4974versión On-line ISSN 2237-9622

Epidemiol. Serv. Saúde vol.29 no.5 Brasília  2020  Epub 09-Nov-2020

http://dx.doi.org/10.1590/s1679-49742020000500008 

Original Article

Magnitude and determinants of neonatal and postneonatal mortality in Goiânia, Goiás, Brazil: a retrospective cohort study, 2012 *

Caio Átila Saloio (orcid: 0000-0003-2159-6141)1  , Otaliba Libânio de Morais Neto (orcid: 0000-0002-3786-318X)2  , Dayanne Augusta Gonçalves (orcid: 0000-0003-3744-9867)1  , Hugo Estevam Marques Bessa (orcid: 0000-0003-2361-2563)1  , Jadson Pinheiro Coelho Júnior (orcid: 0000-0002-3133-3145)1  , May Socorro Martinez Afonso (orcid: 0000-0001-8122-6770)3  , Simone Resende de Carvalho (orcid: 0000-0001-8400-1067)4 

1Universidade Federal de Goiás, Faculdade de Medicina, Goiânia, GO, Brazil

2Universidade Federal de Goiás, Instituto de Patologia Tropical e Saúde Pública, Goiânia, GO, Brazil

3Hospital das Clínicas da Universidade Federal de Goiás, Goiânia, GO, Brazil

4Secretaria de Estado da Saúde de Goiás, Goiânia, GO, Brazil

Abstract

Objective:

To estimate magnitude and determinants of neonatal and postneonatal mortality rates in Goiânia, Brazil, 2012.

Methods:

This was a retrospective cohort study based on data linkage of the Live Birth Information System and the Mortality Information System. Logistic regression was used to evaluate factors associated with neonatal and postneonatal death.

Results:

Neonatal mortality (0-27 days of life) was 9.4 deaths per 1,000 live births; while postneonatal mortality (28-364 days of life) was 3.0 deaths per 1,000 live births. Neonatal mortality associated factors were: 0-3 prenatal care visits (OR=13.10 – 95%CI 7.48;22.96), 19-34-week pregnancy (OR=6.25 – 95%CI 2.26;17.29), birth weight <1,500g (OR=62.42 – 95%CI 22.72;171.48) and cesarean delivery (OR=0.54 – 95%CI 0.37;0.79). Postneonatal mortality associated factors were: 0-3 prenatal care visits (OR=4.16 – 95%CI 1.51;11.43) and birth weight <1.500g (OR=18.74 – 95%CI 4.04;87.00).

Conclusion:

A low number of prenatal care visits, premature childbirth and low birth weight were the main risk factors for neonatal and postneonatal mortality.

Keywords: Child Health; Infant Mortality; Neonatal Mortality; Health Services; Information Systems; Cohort Studies

Introduction

Infant mortality is an indicator of a population's health status and quality of life. Monitoring infant mortality serves to inform Public Health policies aimed at the well-being of women and children. 1,2 Globally, the infant mortality rate (IMR) fell from 63 to 35 deaths per 1,000 live births between 1990 and 2012.

In the municipality of Goiânia, capital of the state of Goiás, there has been a reduction in both the absolute number of deaths and in mortality rates.

Geographic inequalities become clear when noting that in high-income countries IMR fell from 12 to 5 deaths per 1,000 live births between 1990 and 2012, while in low-income countries the rate decreased from 104 to 56 deaths per 1,000 live births in the same period. 3 According to more recent United Nations Children's Fund (UNICEF) data, there was an additional reduction in global IMR from 35 to 29 deaths per 1,000 live births in the period 2012-2018. 4 In the municipality of Goiânia, capital of the state of Goiás, there has been a reduction in both the absolute number of deaths and in mortality rates. IMR fell from 17.8 (1996) to 12.9 (2012) and then to 10.5 deaths per 1,000 live births in 2018, being lower than the national average in 2012 and 2018: 13.5 and 12.2 deaths per 1,000 live births, respectively. 5

The neonatal component of infant mortality – infant deaths occurring between 0 and 27 days of life – is strongly influenced by the quality of health care provided, while the postneonatal component – infant deaths occurring between 28 and 364 days of life – is strongly influenced by socioeconomic and environmental determinants. In the 1970s, the main causes of infant deaths were communicable diseases and nutritional diseases. With effect from the early 1990s, there was a change in this predominance which until then had been attributed to perinatal illnesses. The determinants of the new configuration of infant deaths include reduced fertility rates, the scaling up of Primary Health Care, improved maternal schooling and expansion of immunization coverage. 68 Brazil met the Millennium Development Goal of reducing infant mortality by two thirds by 2015, taking the rate in 1990 as the reference; 9 however, current levels of infant mortality in Brazil, comparatively, remain higher than those of high-income countries, 10 suggesting that Brazil should set a more ambitious target for reducing this indicator.

One of the main challenges to reducing infant mortality, in view of current levels, is to reduce intra-urban inequality. Two studies that assessed likelihood of infant death in live birth cohorts in Goiânia's health districts between 1992 and 1996, 11,12 identified a heterogeneous spatial pattern of occurrence, reporting neonatal mortality in high-risk areas distributed over all health districts, while greater risk of postneonatal mortality was concentrated in the Northwestern and Northern health districts. Two decades later, however, there are no new studies dedicated to assessing the intra-urban profile of infant mortality in Goiânia's health districts.

The main objective of this study was precisely that of estimating the magnitude of the neonatal and postneonatal components of infant mortality, as well as associated factors, in the cohort of live born babies of mothers resident in Goiânia in 2012.

Methods

This was a retrospective cohort study using nominal data from the Live Birth Information System (SINASC) database for the year 2012 and from the Mortality Information System (SIM) database for 2012 and 2013 – i.e. data on babies born alive in 2012 who died in 2012 or 2013.

The study site was Goiânia, GO, in the Midwest region of Brazil. In 2012 the municipality had an estimated population of 1,333,767 inhabitants. According to 2019 data, Goiânia has a per capita oss domestic product of R$ 28,343.10. 13 The municipality is divided into 65 urban planning districts defined in 1992 following socioeconomic homogeneity criteria. 14 These districts currently form seven geographical health regions, referred to as the Southern, Campinas-Central, Eastern, Northern, Western, Southwestern and Northwestern health districts.

In Goiânia the Family Health Strategy covers 68,351 families and the city has three public maternity hospitals. One of them is a reference hospital for high-risk cases managed by the Goiás state government, while another of them is a federal service located in the Federal University of Goiás Hospital das Clínicas . In addition to public services, there are also obstetric and neonatal beds paid for by the Brazilian National Health Service (SUS) in private and charity hospital maternity units. 13

The nominal databases were provided by the Goiás State Health Department.

The study database was comprised of all the 21,346 live born babies of mothers resident in the municipality of Goiânia in 2012 who had Live Birth Certificates registered on the SINASC system in 2012. Neonatal and postneonatal deaths occurring in the 2012 live born baby cohort were identified on the SIM system by linking the two databases.

The outcomes of the study were infant deaths – defined as deaths of live born babies under 1 year old – divided into neonatal deaths (0-27 days of life) and postneonatal deaths (28-364 days of life).

In order to analyze determinant factors of infant mortality, the variables were categorized as distal determinants, intermediate determinants and proximal determinants of infantile death, as per the classification proposed by Mosley & Chen: 15

  1. Distal determinants

    • level of schooling (complete higher education; high school/incomplete higher education; complete elementary education; incomplete elementary education or no schooling);

    • mother's race/skin color (white; brown; black; other [indigenous and yellow]); and

    • mother's marital status (married/common law marriage; single/separated/widowed).

  2. Intermediate determinants

    • mother's age (in years: 20-34; 35 and over; 10-19);

    • delivery type (vaginal; cesarean); and

    • number of prenatal care visits (7-14; 15-20; 4-6; 0-3).

  3. Proximal determinants

    • weeks of pregnancy (37-45; 34-36; 19-34);

    • birth weight (2,500g and over; 1,500 to 2.499g; under 1.500g); and

    • sex of the newborn (female; male).

  4. Mother's health district of residence (Southern; Campinas-Central; Eastern; Northern; Western; Southwestern; Northwestern).

In order to identify deaths in the 2012 live birth cohort, a probabilistic linking procedure was performed between the databases using the OpenRecLink 3.1 computer program. This procedure was comprised of the following stages:

  1. standardization – standardization of variables and checking for phonetic and spelling mistakes that could interfere with record matching;

  2. blocking – creation of logical blocks of files, done by the computer program, taking the name of the mother of the live born baby held on each record;

  3. matching – definition of the linkage variables (name; date of birth; mother's name) and the comparison variables used in the next stage (name; date of birth; mother's name; sex; municipality of residence), based on the sensitivity and specificity parameters adopted, according to the matrix generated by the computer program for the dataset;

  4. manual inspection – final stage classifying each pair of records as a true or false match, by categories defined by probability scores given at the end of the matching stage; and

  5. merging – retrieval of the original variables present in the complete databases.

IMRs in the neonatal and postneonatal periods were estimated by taking neonatal deaths (0-27 days of life) and postneonatal deaths (28-364 days of life) for the years 2012 and 2013 belonging to the 2012 live birth cohort as the numerator, and live born babies of mothers resident in Goiânia in 2012 as the denominator:

IMR=Totalnumberofdeathsofbabiesunder            1yearoldbornalivein2012Totalnumberoflivebirthsin2012X1,000neonatalIMR=Numberofdeathsat027complete    daysoflifeofbabiesbornalive                              in2012Totalnumberoflivebirthsin             2012x1,000X1,000postneonatalIMR=Numberofdeathsat28364completedaysoflifeofbabies           bornalivein2012Totalnumberoflivebirthsin             2012x1,000X1,000

Infant deaths and live-born babies were georeferenced in Goiânia's health districts, in order to estimate the neonatal and postneonatal mortality rates for each district.

Bivariate and multivariate logistic regression was performed in order to analyze determinants of infant mortality. Crude and adjusted odds ratios (OR) and their respective 95% confidence intervals (95%CI) were calculated. Variables with a p-value of less than 0.20 in the bivariate analysis were included in the multivariate analysis, on each hierarchical level. Variables with p<0.05 in each hierarchical level and those found to be a confounding factor for the other variables on the same hierarchical level were kept in the model. The analysis was conducted according to hierarchical levels of determination: distal, intermediate and proximal. The distal level variables were adjusted only by the variables on the same level. The intermediate level variables were adjusted between each other and by the significant distal level variables. The proximal level variables were adjusted between each other and by the significant distal and intermediate level variables. The quality of the fit of the model was assessed using the Hosmer & Lemeshow test, with values between 0.9 and 1.0.

The reference categories for each variable were defined based on the literature we reviewed as well as on previous studies conducted in Goiânia, in order to enable comparability of the results in different years.

The OpenReclink 3.1 computer program was used for the probabilistic linkage between the databases and the IBM® SPSS Statistics 25 computer program was used to perform statistical analysis.

The Federal University of Goiás Research Ethics Committee approved the study project as per Opinion No. 1.058.681, issued on May 11th2015

Results

The final database was comprised of a total of 21,346 live-born babies of mothers resident in the municipality of Goiânia in 2012. Data completeness quality was greater than 95% for the selected variables, with the exception of mother's race/skin color and weeks of pregnancy, with 80.9% and 86.0% respectively ( Table 1 ). We identified 21,081 survivors and 265 infant deaths in the 2012 live birth cohort, with 201 deaths in the neonatal period and 64 deaths in the postneonatal period. The IMR was 12.4 deaths per 1,000 live births: neonatal IMR was 9.4 deaths per 1,000 live births, while postneonatal IMR was 3.0 deaths per 1,000 live births. In the early neonatal period (0-6 days of life), there were 6.6 deaths per 1,000 live births; while in the late neonatal period (7-27 days of life) there were 2.8 deaths per 1,000 live births.

Table 1 Description and percentage completeness of the independent variables, by determinant levels, in Goiânia, 2012 

Variable Category Completeness quality (%)
Neonatal Postneonatal
Distal determinants
Schooling Complete higher education
High school/incomplete higher education
Complete elementary education
Incomplete elementary education or no schooling
97.0 96.9
Mother's race/skin color White
Brown
Black
Other (indigenous and yellow)
80.9 80.9
Mother's marital status Married/common law marriage
Single/separated/widowed
97.6 97.6
Intermediate determinants
Mother's age (years) 20 - 34
≥35
10 - 19
99.9 99.9
Delivery type Vaginal
Cesarean
99.8 99.9
Number of prenatal care visits 7 - 14
15 - 20
4 - 6
0 - 3
95.3 95.3
Proximal determinants
Weeks of pregnancy 37 - 45
34 - 36
19 - 34
86.0 86.0
Birth weight ≥2.500g
1.500 a 2.499g
<1.500g
99.9 99.9
Sex of the newborn Female
Male
99.9 99.9
Mother's health district of residence Southern
Campinas-Central
Eastern
Northern
Western
Southwestern
Northwestern
98.2 98.2

With regard to the neonatal period and factors associated with mortality, no statistically significant determinant was found for the distal level. On the other hand, the following factors were found for the intermediate level: mothers who had 4-6 prenatal care visits (OR=4.57 – 95%CI 2.96;7.04) and 0-3 prenatal care visits (OR=13.10 – 95%CI 7.48;22.96). Cesarean delivery was found to be a protective factor (OR=0.54 – 95%CI 0.37;0.79) ( Table 2 ). The following were risk factors for the proximal determinants: 34-36 weeks of pregnancy (OR=4.11 – 95%CI 1.92;8.76), 19-34 weeks of pregnancy (OR=6.25 – 95%CI 2.26;17.29), birth weight between 1,500 and 2,499g (OR=2.70 – 95%CI 1.21;6.07) and birth weight under 1,500g (OR=62.42 – 95%CI 22.72;171.48) ( Table 2 ).

Table 2 Determinants of neonatal deaths in the cohort of live born babies of mothers resident (n=21,346) in Goiânia, 2012 

Category Deaths Total a (%) Neonatal mortality rate p-value OR b (95%CI c )
Determinantes distais
Schooling 0.440
Complete higher education 53 4,558 (22.1) 11.63
High school/incomplete higher education 97 11,641 (56.4) 8.33 0.75 (0.51;1.12)
Complete elementary education 42 3,886 (18.8) 10.81 0.87 (0.52;1.48)
Incomplete elementary education or no schooling 5 551 (2.7) 9.07 0.47 (0.11;1.97)
Total 197 20,636 9.55
Mother's race/skin color 0.570
White 74 6,895 (40.0) 10.73
Brown 79 9,713 (56.4) 8.13 0.85 (0.60;1.21)
Black 2 461 (2.7) 4.34 0.47 (0.11;1.96)
Other (indigenous and yellow) 2 149 (0.9) 13.42 1.42 (0.34;5.87)
Total 157 17,218 9.12
Mother's marital status 0.660
Married/common law marriage 133 14,196 (68.4) 9.37
Single/separated/widowed 61 6,568 (31.6) 9.29 0.92 (0.64;1.33)
Total 194 20,764 9.34
Intermediate determinants
Mother's age (in years) 0.210
10-19 36 2,891 (13.6) 12.45 0.99 (0.58;1.69)
20-34 132 15,819 (74.3) 8.34
≥35 33 2,567 (12.1) 12.86 1.55 (0.95;2.52)
Total 201 21,277 9.45
Delivery type <0.001
Vaginal 88 5,298 (24.9) 16.61
Cesarean 112 15,952 (75.1) 7.02 0.54 (0.37;0.79)
Total 200 21,250 9.41
Number of prenatal care visits <0.001
15-20 3 412 (2.0) 7.28 0.89 (0.22;3.69)
7-14 75 14,508 (71.6) 5.17
4-6 70 4,650 (22.9) 15.05 4.57 (2.96;7.04)
0-3 32 702 (3.5) 45.58 13.10 (7.48;22.96)
Total 180 20,272 8.88
Proximal determinants
Weeks of pregnancy <0.001
37-45 30 16,147 (88.2) 1.86
34-36 27 1,630 (8.9) 16.56 4.11 (1.92;8.76)
19-34 110 523 (2.9) 210.33 6.25 (2.26;17.29)
Total 167 18,300 9.13
Birth weight <0.001
≥2.500g 48 19,454 (91.4) 2.47
1.500 a 2.499g 34 1,564 (7.3) 21.74 2.70 (1.21;6.07)
<1.500g 118 262 (1.2) 450.38 62.42 (22.72;171.48)
Total 200 21,280 9.40
Sex 0.640
Female 81 10,541 (49.6) 7.68
Male 115 10,716 (50.4) 10.73 1.12 (0.69;1.82)
Total 196 21,257 9.22

a)Unknown/blank cases were excluded from the analysis.

b)OR: adjusted odds ratio .

c)95%CI: 95% confidence interval.

In the postneonatal period, the factor found to be associated with mortality was 0-3 prenatal care visits (OR=4.16 – 95%CI 1.51;11.43) ( Table 3 ). On the proximal level the associated factors were: birth weight between 1,500 and 2.499g (OR=6.71 – 95%CI 2.58;17.51) and birth weight under 1,500g (OR=18.74 – 95%CI 4.04;87.00) ( Table 3 ).

Table 3 Infant deaths by health district of residence in the cohort of live born babies of mothers resident (n=21,346) in Goiânia, 2012 

Category Deaths Total a (%) Postneonatal mortality rate p-value OR b (95%CI c )
Distal determinants
Schooling 0.540
Complete higher education 8 4,513 (22.0) 1.77
High school/incomplete higher education 39 11,583 (56.5) 3.37 1.61 (0.71;3.65)
Complete elementary education 13 3,857 (18.8) 3.37 1.04 (0.35;3.09)
Incomplete elementary education or no schooling 1 547 (2.7) 1.83 1.06 (0.13;8.89)
Total 61 20,500 2.98
Mother's race/skin color 0.620
White 21 6,842 (40.0) 3.07
Brown 27 9,661 (56.5) 2.79 0.80 (0.43;1.49)
Black 2 461 (2.7) 4.34 1.39 (0.32;6.12)
Other (indigenous and yellow) 1 148 (0.9) 6.76 2.30 (0.31;17.37)
Total 51 17,112 2.98
Mother's marital status 0.100
Married/common law marriage 34 14,097 (68.3) 2.41
Single/separated/widowed 28 6,535 (31.7) 4.28 1.65 (0.91;2.97)
Total 62 20,632 3.01
Intermediate determinants
Mother's age (in years) 0.490
10-19 9 2,864 (13.5) 3.14 0.85 (0.34;2.10)
20-34 47 15,734 (74.4) 2.99
≥35 8 2,542 (12.0) 3.15 1.59 (0.69;3.67)
Total 64 21,140 3.03
Delivery type 0.990
Vaginal 8 5,228 (24.8) 1.53
Cesarean 46 15,886 (75.2) 2.90 1.00 (0.49;2.01)
Total 64 21,114 3.03
Number of prenatal care visits 0.050
15-20 1 410 (2.0) 2.44 1.28 (0.17;9.52)
7-14 36 14,469 (71.8) 2.49
4-6 18 4,598 (22.8) 3.91 1.21 (0.58;2.50)
0-3 5 675 (3.3) 7.41 4.16 (1.51;11.43)
Total 60 20,152 2.98
Proximal determinants
Weeks of pregnancy 0.160
37-45 29 16,146 (88.8) 1.80
34-36 7 1,610 (8.9) 4.35 1.27 (0.42;3.90)
19-34 18 431 (2.4) 41.76 3.40 (0.95;12.11)
Total 54 18,187 2.97
Birth weight <0.001
≥2.500g 33 19,439 (91.9) 1.70
1.500 a 2.499g 18 1,548 (7.3) 11.63 6.71 (2.58;17.51)
<1.500g 13 157 (0.7) 82.80 18.74 (4.04;87.00)
Total 64 21,144 3.03
Sex 0.520
Female 36 10,496 (49.7) 3.43
Male 28 10,629 (50.3) 2.63 0.79 (0.39;1.60)
Total 64 21,125 3.03

a)Unknown/blank cases were excluded from the analysis.

b)OR: adjusted odds ratio .

c)95%CI: 95% confidence interval.

With regard to magnitude of mortality in Goiânia's health districts, the estimated mortality rate in the neonatal period varied between 6.45 deaths per 1,000 live births in the Northern district and 10.32 deaths per 1,000 live births in the Southwestern district. In the postneonatal period, mortality varied between 1.30 death per 1,000 live births in the Northern district and 4.23 deaths per 1,000 live births in the Western district. No statistically significant differences were found ( Table 4 ).

Table 4 Determinants of postneonatal deaths in the cohort of live born babies of mothers resident (n=21,346) in Goiânia, 2012 

Health district Deaths Total a (%) Infant mortality rate p-value OR b (95%CI c )
Neonatal death 0.630
Southern 29 3,191 (15.7) 9.09
Campinas-Central 21 2,921 (14.4) 7.19 0.79 (0.45;1.39)
Eastern 18 2,682 (13.2) 6.71 0.74 (0.41;1.33)
Northern 15 2,327 (11.4) 6.45 0.71 (0.38;1.32)
Western 19 2,373 (11.7) 8.01 0.88 (0.49;1.57)
Southwestern 37 3,587 (17.6) 10.32 1.14 (0.70;1.85)
Northwestern 29 3,255 (16.0) 8.91 0.98 (0.58;1.64)
Total 168 20,336 8.26
Postneonatal death 0.580
Southern 8 3,170 (15.7) 2.52
Campinas-Central 7 2,907 (14.4) 2.41 0.95 (0.35;2.63)
Eastern 7 2,671 (13.2) 2.62 1.04 (0.38;2.87)
Northern 3 2,315 (11.4) 1.30 0.51 (0.14;1.94)
Western 10 2,364 (11.7) 4.23 1.68 (0.66;4.26)
Southwestern 13 3,563 (17.6) 3.65 1.45 (0.60;3.50)
Northwestern 8 3,234 (16.0) 2.47 0.98 (0.37;2.62)
Total 56 20,224 2.77

a)Unknown/blank cases were excluded from the analysis.

b)OR: adjusted odds ratio .

c)95%CI: 95% confidence interval.

Discussion

This study estimated magnitude of neonatal and postneonatal mortality in the municipality of Goiânia and its health districts. Mortality magnitude rates differed between districts, with greatest risk of neonatal mortality in the Southwestern district and least risk in the Northern district. The main factors associated with mortality in the neonatal and postneonatal periods were inadequate number of prenatal care visits, premature birth and low birth weight.

Infant mortality rates in the neonatal and postneonatal periods in Goiânia in 2012 were lower than those found by two studies that estimated probability of death in the neonatal and postneonatal periods in the 1992 to 1996 live birth cohorts. Comparison between the rates in 2012 with those of 1992 and 1996 showed a reduction in percentage change of 14.5% and 24.5% respectively, for the two periods. 11,12 Comparison of the rates found in Goiânia with those of other countries shows that they were higher than those found in high-income countries. 10

Reduction in the neonatal period was less than in the postneonatal period; probably because of socioeconomic improvements and improvement in the level of schooling of mothers living in the poorer regions of the city. In the 1990s, the Northwestern health district had the highest risks of mortality and the worst socioeconomic indicators when compared to the other districts; it was also the district with the largest percentage reduction in infant mortality between 1996 and 2012, when Primary Health Care expanded to provide 100% coverage of the district's population and a maternity hospital was built operating with a humanized child delivery model, adequate physical structure and qualified health workers. 11,12,1618

The lower percentage reduction in the neonatal component may be due to early neonatal deaths of babies born to women resident in other municipalities who reported living in the municipality of Goiânia when they received health care: the state capital provides a neonatal intensive therapy unit (ITU) reference service equipped with 98 beds. 19 Availability of neonatal ITU beds in Goiânia is sufficient to meet the needs not only of the population resident in the municipality but also part of the municipalities comprising Goiás state's Integrated Programming Agreement. Indeed, Public Health in Goiânia receives at risk newborns from all over the state as well as from neighboring states. Another hypothesis for this demand from outside the municipality may be low quality prenatal care and absence of obstetric beds in public maternity services in health districts where population density has increased more recently, comprised of people of low socioeconomic level and at high risk of neonatal death. 16,18

In 2012, magnitude of neonatal and postneonatal infant mortality was highest in Goiânia's Southwestern and Western health districts, where the low-income population grew rapidly, as a result of migration between neighborhoods in Goiânia, or from municipalities in the metropolitan region surrounding the capital. Other factors that contributed to this high risk may have been low Family Health coverage and absence of public maternity services in these two regions. 1618

Analysis of the factors associated with neonatal and postneonatal mortality showed that the inadequate number of prenatal care visits was statistically significant for both these components of infant mortality. 1,20 Quality prenatal care, with an adequate number of consultations, laboratory tests and paying due attention to intercurrences, reduces risk of complications during pregnancy and childbirth. 20 A study which assessed a population with characteristics similar to those of Goiânia found that neonatal mortality can be reduced by up to 34% by implementing quality prenatal monitoring. 21

Low birth weight and premature birth were the determinants with the highest odds ratios in the neonatal period. Magnitude of both factors is high, due to their being situated on the most proximal level of the chain of infant mortality determinants. 6 Distal determinants, such as socioeconomic status, schooling, mother's race/skin color, access to quality health services, are hierarchically higher determinants in the low weight and prematurity causality chain, these being the proximal determinants of infant deaths. 6,15 The ‘ Nascer no Brasil ’ survey 22 showed that low weight was the variable with strongest association with neonatal mortality, with prematurity present in almost one third of cases. According to that survey, the main causes of prematurity were increased pregnancy in women over 35 years old, improvement in measuring gestational age and changes in the limit of viability (improvement in recording live births with very low birth weight).

The protective effect of cesarean delivery found by this study, had also been identified in previous studies that also assessed infant mortality in Goiânia in the 1992 cohort and the 1992-1996 cohorts, as well as in analyses of determinants of infant mortality in other Brazilian capitals. 11,12,23,24 This protective effect of cesarean delivery may be related to the fact that in Goiânia 75% of childbirths were via cesarean section, performed in an operating theater, under the care of an obstetrician and with less risk of complications related to normal childbirth – such as amniotic fluid and meconium inhalation, macrosomia and infections. 25 For the purposes of comparison, a study conducted in Florianópolis, SC, found that cesarean sections accounted for 53% of childbirths, with no statistically significant difference in relation to the ‘infant death’ outcome. 1 A case-control study of determinants of infant mortality in 27 Brazilian state capitals, which also has as its study population infant deaths occurring in 2012, found that cesarean delivery was a protective factor in its analysis of the capital cities of Brazil's Midwest region and for all the Brazilian state capitals. 23 Studies conducted in the United States show that there is low mortality among high-risk babies born alive in hospitals that have neonatal ITU beds, including those with extremely low birth weight. 21,26

There was no difference in the likelihood of death in relation to the ‘schooling’, ‘mother's race/skin color', ‘marital status’ and ‘mother's age' variables. A systematic review 26 studying determinant factors of infant death showed that statistical analysis methods have limitations with regard to assessing determinants of infant mortality found on different hierarchical levels of determination. Proximal factors have greater statistical significance, when compared to distal and intermediate determinants, which may explain the stronger association of more proximal factors, such as low birth weight and prematurity, and absence of statistical significance of schooling and mother's race/skin color. 26 Cross-sectional studies that assessed determinants of neonatal near misses in Joinville, SC, 27 and in Teresina, PI, 28 also did not find statistically significant association between mother's race/skin color or marital status and infant death.

Standing out among the limitations of this study is the use of secondary SIM and SINASC data, which may have quality-related problems in terms of the filling in of some of the variables. SIM can have shortcomings in data processing and in the filling in of death certificates not in keeping with the standard recommended by the Ministry of Health. SIM and SINASC coverage was 90% in the state of Goiás in 2012, 29 with 97.9% variable completeness in the period 2006-2010. 30 The Ministry of Health, in partnership with state and municipal health departments, has made progress with increasing death certificate coverage and completeness quality; although there are still limitations in relation to infant mortality, so that indirect estimates need to be used in states with a high percentage of underreporting. 29,30

The results of this study can inform municipal management of the Brazilian National Health System (SUS) and social health policy watchdog efforts in Goiânia, to achieve greater knowledge of infant mortality magnitude and its main risk factors. The results enable identification of infant mortality inequalities between Goiânia's health districts, as well as the main factors associated with mortality in the neonatal and postneonatal periods. Their use is also recommended for guiding, expanding and qualifying prenatal, childbirth and newborn care in Goiânia's health districts.

*Article derived from the Master's Degree dissertation entitled ‘Determinants and predictors of infant deaths in the state of Goiás, 2012: use of database linkage with SUS health information systems’, defended by Simone Resende de Carvalho at the Federal University of Goiás Tropical Medicine and Public Health Postgraduate Program in 2017.

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Received: May 01, 2020; Accepted: July 17, 2020

Correspondence: Caio Átila Saloio – Universidade Federal de Goiás, Faculdade de Medicina, Rua 235, S/N, Setor Leste Universitário, Goiânia, GO, Brazil. Postcode: 74605-050 . E-mail: caioatilasaloio@gmail.com

Associate editor: Lúcia Rolim Santana de Freitas - orcid.org/0000-0003-0080-2858

Authors' contributions

Saloio CA and Morais Neto OL contributed to the study concept and design, data acquisition, analysis and interpretation, drafting and critically reviewing the contents of the manuscript. Gonçalves DA, Bessa HEM and Coelho Junior JP contributed to data acquisition, analysis and interpretation, drafting and critically reviewing the contents of the manuscript. Carvalho SR and Afonso MSM contributed to the study concept and design, drafting and critically reviewing the contents of the manuscript. All the authors have approved the final version of the manuscript and are responsible for all aspects thereof, including the guarantee of its accuracy and integrity.

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