Evolution of the infant, neonatal and post-neonatal mortality in a big city of Amazonia, Brazil.
Since the 1980s, although less during the last decade, the infant mortality rates in Brazil presented a falling disposition. This gain in infant health, however, was mainly in exchange for reduced deaths during the post-neonatal period (deaths between 28 days and one year of life). There has been a deliberate attempt to improve outcomes through enhanced public health policies. In contrast, the mortality rate for the neonatal period (deaths occurring from birth to 27 days) presented a very slow declining tendency, influenced by the permanence of high mortality levels caused by factors linked to pregnancy and childbirth (Monteiro, Iunes, & Torres, 1995).
Manaus, the capital of the state of Amazonas is located on the left border of the Rio Negro, close to the encounter of the rivers Negro and Solimoes. Founded in 1669, Manaus in the native indigenous language, means "Mother of the Gods." This name was given to the city in memory of an ancient tribe called "Manaos." In 1856 Manaus became the capital city of the province of the Amazonas. From 1870 to the first years of the 20th century, Manaus flourished under heavy economical and urban development brought by rubber exploitation but declined sharply during the first decade of the century due to competition from Malaysian rubber. In an effort to take Manaus out of the heavy economical recession that succeeded after the rubber crisis, a Free Zone was created in 1967 to bring investments and attract work forces to industries and trade in the developing Occidental Amazon.
Manaus has now almost two million habitants spread over 63 neighborhoods in continuous expansion. Since most of these neighborhoods were not properly planned, much of the local population resides in poor living conditions. Manaus has a public birth clinic system which offers 497 beds for common accommodation and 73 neonatal beds for intensive care and semi-intensive care, distributed over five birth clinics. In the private system there are 48 beds for common accommodation, five beds for intensive care, and 10 beds for semi-intensive care distributed over four facilities that perform deliveries.
Besides congenital malformations, neonatal mortality is determined in Brazil by perinatal causes, such as underweight newborns, problems related to premature childbirth, immediate postpartum issues, and the precariousness of the prenatal and childbirth assistance health services. The majority of neonatal deaths are considered preventable through the adoption of proper measures, assessment, and care during pregnancy and childbirth (Victora, Grassi, & Schmidt, 1994).
Despite improvements done in the last ten years, such as the building of three new birth centers and training of specialized professionals, the neonatal mortality rate remains higher than the national average. This Study aims to analyze the evolution of infant mortality and it is components, especially the neonatal component, between 2001 and 2005, seeking for information beyond that contained in the official database system in which quality is questionable.
This paper is a descriptive study about infant, neonatal (early and late) and post-neonatal mortality in Manaus, between 2001 and 2005. To calculate the infant mortality rate during the neonatal period, SIM (Mortality Information System) from the Ministry of Health was used. In order to calculate the rate of neonatal mortality (early and late), the data referred to childbirths in the city was collected from the Health Information Department of the Municipal Health Secretary. Bear in mind that the data for the childbirth records are forwarded by birth clinics to be processed by this department, and later sent to the SINASC (Born Alive Information System). The analysis was made using Microsoft Excel. The research Project had the assent of the Committee for Ethics in Research from the Federal University of Amazonas-UFAM (no 252/2006 14/12/06).
The number of live births registered by the Health Information Department of the Health Secretary of the studied city increased from 37.478 in 2001 to 38.046 in 2005. The infant mortality rate shows decline of 31.58%, from 25.68 for one thousand live births in 2001, to 17.57 in 2005. The neonatal mortality rate represents two thirds (63.23%) of the infant mortality rate against one third (37.33%) for the postneonatal mortality rate. And the early neonatal mortality rate predominates, representing 78% of the neonatal deaths against 22% for the late neonatal mortality rate. In the total of infant deaths, the early neonatal mortality represents almost half (Rede Interagencial de Informacoes para a Saude, 2007).
All the rates had a fall of at least 24% between 2001 and 2005, the most major of which was the late neonatal mortality which was 48.52%. The infant and the neonatal mortalities presented a reduction of 31.58 % and 34.68 % respectively. The early and late neonatal mortalities decreased less, but still considerably (29.33% and 24.33% respectively).
Hyaline Membrane Disease (neonatal respiratory distress syndrome) was the main cause of death at birth for all the years studied. Other respiratory diseases have had an important reduction between 2001 and 2005. Other measures including neonatal sepsis (one case out of seven), other perinatal infections (more than one case out of ten), intrauterine hypoxia and asphyxia at birth (less than one case out of ten) hardly changed between 2001 and 2005. Specific infections of the perinatal period (less than one case out of twenty) and congenital pneumonia (one case out of almost sixty) presented some variation but didn't change in this period. Of note, congenital malformations almost doubled, being the cause of death in more than one case out six deaths of newborns in 2004 and 2005.
During the study, 67.05% of the babies who died were underweight newborns (less than 2500g). Of those, two thirds were extremely underweight newborns (less than 1500 g). Underweight newborns increased from 63% in 2001 to 69.03% in 2005 among the newborns who died. Extremely underweight newborns increased from 39.96% in 2001 to 49.17% in 2005 among the newborns who died. Deaths of newborns born before 37 weeks gestation decreased from 74.69% in 2001 to 69.64% in 2005. In a category of babies less than 37 weeks gestation, very premature babies (less than 28 weeks gestation) represented 28% in 2001 and 45.78% in 2005.
The reduction of the infant mortality rate in Brazil, and especially of the post-neonatal mortality, is well explained by the actions taken by the Ministry of Health in recent years for the health promotion of children with emphasis in programs to fight malnutrition, diarrhea, and dehydration, as well as promote vaccination campaigns. However, although it has proceeded to the predominance of the neonatal component, Brazilian rates are quite high if compared to others countries, since these deaths still coexist with the occurrence of avoidable deaths with actions in primary and secondary care (Chaad & Cervini, 1980; Monteiro, Iunes, & Torres, 1995).
With respect to information concerning the births, the comparison between the number of births occurred in the hospitals of the national health system and the ones declared by the SINASC (national information system about live births) still shows deficiencies in some states of the country, although of lesser magnitude than the ones presented by the SIM (national information system about mortality) (Schwarcz & Diaz, 1992; Szwarcwald, Leal, Andrade, & Souza, 2002). Despite having fallen, the infant mortality rate observed in Manaus is still considered high if compared with cities well developed in the south and the south-east of Brazil, because access to health care of good quality during the perinatal period is less (Chaad and Cervini, 1980).
As several studies have shown, in Brazil (Szwarcwald et al., 2002 ; Rede Interagencial de Informacoes para a Saude, 2007), neonatal deaths represent the highest percentage of deaths among children under one year: 63.23%. It is also worth noting that, inside neonatal mortality, early neonatal mortality which represented 72% of the neonatal mortality in 2001, increased to 78% in 2005; while late neonatal mortality, which corresponds to 28% of the neonatal mortality in 2001, decreased to 22% in 2005. Two recent studies (Ribeiro and Silva, 2000; Magalhaes, 2000) analyzing trends of neonatal mortality in Sao Luis do Maranhao and in Juiz de Fora, Minas Gerais, point to the occurrence of this phenomenon.
Unlike developed countries, where the first cause of mortality in the perinatal period is congenital malformation--virtually impossible to avoid--in Brazil most perinatal deaths are determined by conditions of care within the health services. The most frequent cause of death identified is Hyaline Membrane Disease, which is directly related to prematurity, and which decreased in 22.38% between 2001 and 2005.
Another cause of neonatal death, in same proportion in 2005 is congenital malformations, which are difficult to explain and, for this reason, deserve a specific study. Another main cause of death is infection--specific or non-specific to the perinatal period; neonatal sepsis and congenital pneumonia represent together one-third of deaths in newborns, pointing both to unfavorable conditions of the home environment and hospital environment, and to the detection and early treatment of infections. Intrauterine hypoxia, neonatal asphyxia and other respiratory diseases seen in newborns correlate to assistance during the childbirth. Efforts to improve must involve not only the access to prenatal care of good quality, but also measures for continuity of care until the time of birth, along with adequate hospital care (Sarinho, Djalma, Silva, & Lima, 2001; d'Orsi & Carvalho, 1998).
In almost all years studied, two thirds of the deaths were of newborns with birth weights less than 2,500g, considered low birth weight, with an increase of 6% between 2001 and 2005. There are two mechanisms which lead to low birth weight: prematurity and intrauterine growth retardation, which can be explained by infections, maternal malnutrition and smoking. The increase of extremely underweight newborns inside the underweight newborns (7.8% between 2001 and 2005) can be linked to gestational age, but also to the age of the mother, given the high rate of pregnant adolescents in the studied city.
In a study conducted at the University of Alabama (Luo & Kalberg, 2001), underweight and low Apgar test results have been pointed to as the most important predictors of neonatal mortality. Another study accomplished in Goiania (Morais, Neto, & Barros, 2000) found odds ratios significant in children underweight at birth (OR=27.60; CI=95%: 20.40-37.33) and pregnancy less than 37 weeks (OR=37.68; CI=95%: 28.35-50.06). This variable has a very important relationship with disease and death in the first year of life.
In our study, we identified a very high prematurity rate: 68.4% of the deaths, but with a decrease of 5% between 2001 and 2005, while extreme prematurity rose 17.8% in relation to total premature babies who died. Regarding risk factors for prematurity, the lack of pathophysiological knowledge of labor and delivery makes it difficult to develop prophylactic measures against prematurity. However, the identification of pregnant women who present risk factors for this occurrence is an important step; knowledge of etiology of prematurity is also essential in order to identify and prevent prematurity early. (Marcondes, 1994). Among these factors are race, age, nutritional status, weight gain during pregnancy, socio-economical level, professional activity, smoking, drug use, follow up prenatal appointments, clinical intercurrences, fetal conditions, and twin or multiple gestations (Marcondes, 1994) besides many other obstetric factors (Freitas, Martins-Costa, Ramos, & Magalhaes, 2001).
Infant mortality in the city of Manaus decreased by one third between 2001 and 2005, and can be explained, as it can in the entirety of Brazil, by improvements of public health policies. However, it is still considered high in relation to well developed cities in the south and south-east regions of Brazil. The late neonatal component presented the largest drop. As basic causes of death, infectious causes remain very high. For every three newborns who died, two were premature and underweight, the proportion of extremely underweight newborns increased, which can be linked to the high rate of pregnant adolescents in Manaus. The reduction of neonatal mortality, necessarily, is linked to a better understanding of its occurrence by health professionals and especially childbirth educators who teach not only women in developing countries, but who might also have the opportunity to teach emigrant Brazilian women, or Brazilian women encountered during an educator's travels. The newborn and pregnancy characteristics, important indicators of a baby's health, can be used as warning signs for guidance during clinical care and within a childbirth educator's activities. Correct completion of the birth certificate and the declaration of death by the health professionals would enable better data reliability provided by the databases of SIM (Mortality Information System) and SINASC (Born Alive Information System) which may allow for appropriate monitoring of the factors strongly related to infant mortality and its components. Without quality of data, prevention programs cannot correspond to the necessities and cannot be better targeted.
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Evelyne M. T. Mainbourg PhD
Evelyne M.T. Mainbourg has since 1998, been a researcher at the FIOCRUZ (linked to the Health Ministry), working on Amazon populations, especially the living and health conditions for the indigenous city living populations. Dr. Mainbourg is currently teaching at the Master of Nursing of the Federal University of Amazonas, Manaus, Brazil and has five years experience as a nurse in Africa. She has a PhD in Social Sciences/Sociology and graduated in Nursing in France, researcher and teacher at the Master of Saude, Sociedade e Endemias na Amazonia, FIOCRUZ (Fundagao Oswaldo Cruz), and teacher at the Master of Enfermagem, Escola de Enfermagem of the Universidade Federal do Amazonas, Manaus-AM, Brazil.
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|Author:||Mainbourg, Evelyne M.T.|
|Publication:||International Journal of Childbirth Education|
|Date:||Jan 1, 2012|
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