Abstract

This study aims to evaluate the birthplace of preterm infants with less than 34 gestational weeks at birth by type of neonatal care service in maternity hospitals of the “Rede Cegonha” and estimate the maternal factors associated with the inadequate place of birth for gestational age. This national cross-sectional study was performed in 2016/2017 to evaluate health establishments with the Rede Cegonha’s action plan. Information was analyzed from 303 puerperae and the respective health establishments of their births. Newborns were classified by gestational age at birth (<30 and 30-33 weeks) and health establishments as hospitals with neonatal intensive care service, hospitals with intermediate neonatal care service, and hospitals without neonatal care service. Ministerial Ordinance N° 930/2012 was used to classify the birthplace as appropriate for the newborn’s gestational age. Preterm birth prevalence was 37.3 at less than 30 weeks’ gestation and 66.8 at 30-33 weeks. Birth in inappropriate services for the newborn’s gestational age occurred in 6.3%, with significant regional and social differences. Inequalities in access to neonatal care for preterm infants persist in the “Rede Cegonha” despite advances.

Key words
Preterm newborn; Neonatal intensive care unit; Maternal and child health; Maternal and child health services; Health policy

Introduction

Preterm birth is an important public health issue since it is the leading cause of infant mortality and the second among children up to 5 years of age¹1 França EB, Lansky S, Rego MAS, Malta DCF, França JS, Teixeira R, Porto D, Almeida MF, Souza MFM, Szwarcwald CL, Mooney MN, Mohsen AMNV. Principais causas da mortalidade na infância no Brasil, em 1990 e 2015: estimativas do estudo de Carga Global de Doença. Rev Bras Epidemiol 2017; 20(Supl. 1):46-60.^,22 Belizán JM, Hofmeyr J, Buekens P, Salaria N. Preterm birth, an unresolved issue. Reprod Health 2013; 10(1):58.. Also, it is associated with several medium- and long-term health problems³3 Beck S, Wojdyla D, Say L, Betran A. P, Merialdi M, Requejo JH, Rubens C, Menon R, Van Look PF. The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bull World Health Organ 2010; 88(1):31-38. in children.

Annually, about 30 million newborns are at risk, two-thirds of whom are preterm⁴4 World Health Organization (WHO). Born too soon: the global action report on preterm birth. Geneva: WHO; 2012.. It is estimated that 14.8 million births are preterm globally, equivalent to 11% of all live births. Preterm birth affects both high- and low-income countries, and China is the country with the highest absolute number, with the U.S. ranking fourth⁵5 World Health Organization (WHO). Survive and thrive: transforming care for every small and sick newborn: key findings. Geneva: WHO; 2018.. The World Health Organization (WHO) defines preterm birth as that occurring between the 20^th and 37^th gestational week⁶6 World Health Organization (WHO). ICD-11: international statistical classification of diseases and related health problems. Geneva: WHO; 2018., which can be classified by gestational week as extremely preterm (< 28 weeks), very preterm (28 to < 32 weeks), and moderately preterm (32 to < 37 weeks). Within this last category, births occurring from the 34^th to 36^th gestational week are called late preterm⁴4 World Health Organization (WHO). Born too soon: the global action report on preterm birth. Geneva: WHO; 2012..

In Brazil, a national survey on childbirth care carried out in 2011-2012 estimated a preterm birth rate of 11.5% (95% CI 10.3%-12.9%), and 74% were classified as late preterm, with no significant variations by macro-region of the country and type of childbirth funding (public or private)⁷7 Leal MD, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RM, Dias MAB, Moreira ME, Gama SG. Prevalence and risk factors related to preterm birth in Brazil. Reprod Health 2016; 13(Supl. 3):127.. Compared to term, preterm newborns have important limitations in responding to extrauterine stimuli and reacting immunologically to the presence of microorganisms, requiring extensive, comprehensive care starting in the immediate postnatal period and extending throughout childhood⁸8 Platt MJ. Narrative Review: Outcomes in preterm infants. Public Health 2014; 128:399-403.^,99 Barros FC, Rossello JLD, Matijasevich A, Dumith SC, Barros AJD, Santos IS, Mota D, Victora CG. Gestational age at birth and morbidity, mortality, and growth in the first 4 years of life: findings from three birth cohorts in Southern Brazil. BMC Pediatrics 2012; 12:169..

An integrated, hierarchical, and regionalized maternal and child health care network based on maternal risk classification will allow parturients and their babies to receive the necessary care, resulting in greater survival for both. To this end, health facilities must be equipped to address complications, with physical infrastructure and a trained staff¹⁰10 Moreira M, Lopes JMA, Carvalho MO. O recém-nascido de alto risco: teoria e prática do cuidar. Rio de Janeiro: Editora Fiocruz; 2004.^,1111 Bezerra FD, Menezes MAS, Mendes RB, Santos JMJ, Leite DCF, Kassar SB, Gurgel RQ. Cuidado perinatal em um estado do nordeste brasileiro: estrutura, processos de trabalho e avaliação dos componentes do essential newborn care. Revista Paulista de Pediatria 2019; 37(2):140-148..

In Brazil, Ordinance N° 930 of May 10, 2012¹²12 Brasil. Ministério da Saúde (MS). Portaria Nº 930, de 10 de maio de 2012. Define as diretrizes e objetivos para a organização da atenção integral e humanizada ao recém-nascido grave ou potencialmente grave e os critérios de classificação e habilitação de leitos de Unidade Neonatal noâmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2012; 10 maio. recommends that newborns (NB) with a gestational age of fewer than 30 weeks should be admitted to Neonatal Intensive Care Units (NICU)¹²12 Brasil. Ministério da Saúde (MS). Portaria Nº 930, de 10 de maio de 2012. Define as diretrizes e objetivos para a organização da atenção integral e humanizada ao recém-nascido grave ou potencialmente grave e os critérios de classificação e habilitação de leitos de Unidade Neonatal noâmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2012; 10 maio.. There is no recommendation for admission to Conventional Neonatal Intermediate Care (UCINCo) or Kangaroo Neonatal Intermediate Care Unit (UCINCa) based only on the NB’s gestational age. However, newborns with a gestational age of less than 34 weeks are considered high-risk, requiring differentiated care¹³13 Brasil. Ministério da Saúde (MS). Atenção à saúde do recém-nascido: guia para os profissionais de saúde. Brasília: MS; 2014..

This study aims to evaluate the birthplace of newborns with gestational age of less than 34 weeks by type of neonatal care service appropriate for their gestational age in maternity hospitals linked to the “Rede Cegonha” and to verify the factors associated with births occurring in inappropriate places and the related early outcomes.

Methods

This study is nested in the “Evaluation of childbirth and birth care practices in maternity hospitals in the Rede Cegonha” developed by the Federal University of Maranhão (UFMA) and Prof. Sérgio Arouca National School of Public Health (ENSP), Oswaldo Cruz Foundation (Fiocruz), in the 2016-2017 period, under the coordination of the Ministry of Health.

This assessment aimed to verify best practices in labor and childbirth care in all public or private hospitals convened to the Brazilian Unified Health System (SUS), with a Regional Action Plan in the “Rede Cegonha” (RC), and at least 500 births/year in 2015, totaling 606 health establishments. The volume of births in these hospitals accounted for almost 50% of livebirths that year in the country, according to the Live Birth Information System (SINASC)¹⁴14 Brasil. Ministério da Saúde (MS). Portal da Saúde: SINASC. [site da Internet]. [acessado 2019 Nov 10]. Disponível em: ://portal.saude.gov.br/portal/svs/visualizar_texto.cfm?idtxt=2132339
://portal.saude.gov.br/portal/svs/visual... .

All women with a hospital birth during the study period were considered eligible for the primary research. Only those with a severe mental disorder who did not understand the Portuguese language, deaf, or hospitalized in the Intermediate Unit or Intensive Care Unit in the postpartum were excluded. All eligible puerperae admitted to each hospital unit were invited to participate in the study during the fieldwork period. This period was defined by the macro-region in which the hospital was located, namely, three days in the Southeast and Northeast, six days in the North and South, and eight days in the Midwest.

A total of 10,665 puerperae were interviewed, 10,555 who had live births, regardless of weight and gestational age, and 83 stillbirths weighing more than 500 grams or gestational age greater than 22 weeks.

The data collection methods used were face-to-face interviews with key informants (puerperae, health professionals, and managers), data extraction from medical records, analysis of documents, and on-site observation. More detailed information on the methodology of the study is available in Vilella et al.¹⁵15 Vilela MEA, Leal MC, Thomaz EBAF, Gomes MAM, Bittencourt S, Gama SGN, Silva L, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Cien Saude Coletiva 2021; 26(3):789-800..

This study used the information obtained in the interview with women, data extracted from medical records and the on-site observation. The interviews with women were held during hospitalization, at least six hours after birth. An electronic instrument was developed specifically for this study, containing questions about sociodemographic characteristics, information on access to the hospital/maternity, hospital admission, and hospital care during labor and childbirth. Data from hospital records were obtained immediately after the interview with the puerperae using an instrument for data extraction containing information on the care provided to women and their newborns and some neonatal outcomes that occurred up to that moment of hospitalization. The on-site observation sought to evaluate the care processes, infrastructure conditions, and physical plant. A previously prepared script served as a guide for the evaluator as he walked the path taken by the woman – entrance door, reception, admission, observation sector, high-risk pregnancies infirmary, labor and childbirth ambiance, rooming-in, and Neonatal Care Unit.

Women with live births with gestational age of less than 34 weeks were included for this study’s analyses, excluding those who had a stillborn fetus or live births with unknown gestational age (43). Data from hospital records were used to calculate gestational age at birth using an algorithm previously adopted, which favors the calculation of gestational age based on information from ultrasound tests performed during prenatal care¹⁶16 Pereira APE, Leal MC, Gama SGN, Domingues RMSM, Schilithz AOC, Bastos MH. Determining gestational age based on information from the Birth in Brazil study. Cad Saude Publica 2014; 30(Supl. 1):S59-S70..

In the first stage of the analysis, the women’s sociodemographic and obstetric characteristics were described according to the newborn’s gestational age (< 30 weeks and 30-33 weeks). We evaluated region of residence (North, Northeast, South, Southeast, Midwest), self-reported skin color (white, black, brown, yellow, and indigenous), schooling (less than elementary school, complete elementary school, high school and over), marital status (with or without a partner), parity (primiparous, 1-2 previous births, 3 or more previous births), planned pregnancy (yes or no), NB condition at the time of the interview (live or neonatal death), and pilgrimage during labor (search for more than one hospital service for hospitalization for childbirth care, yes or no).

Next, the proportion of newborns born in an inappropriate place, according to their gestational age, and their distribution, according to maternal characteristics, was estimated. Ministerial Ordinance N° 930/2012 was the normative reference used to classify the birthplace as appropriate for gestational age: appropriate place = if gestational age < 30 weeks and admission to service with NICU beds; if gestational age 30-33 weeks and admission to service with NICU or UCINCo/UCINCa beds; inappropriate = if gestational age < 30 weeks and admission to service without NICU beds; if gestational age is 30-33 weeks and admission to services without NICU/UCINCo/UCINCa beds.

Simple and multiple logistic regression models were performed to estimate the association between inappropriate birthplace for gestational age and maternal sociodemographic and obstetric characteristics. The inappropriate birthplace of newborns with less than 34 gestational weeks was considered the outcome variable due to the small number of births in each gestational age range. Maternal characteristics associated with difficulties in accessing neonatal services of greater complexity were used as explanatory variables. All variables with a p-value associated with the regression coefficient below 0.20 in simple logistic regression were included in the multiple regression model. Women who self-reported yellow or indigenous were excluded from this stage of the analysis due to the small number of cases (1.6% and 0.7%, respectively). Crude and adjusted odds ratios and their 95% confidence intervals were obtained from these analyses. As the last step, a description of the early outcomes of preterm newborns was carried out, including the place of hospitalization, transfers, and neonatal deaths up to the moment of the maternal interviews.

Procedures were used for complex samples in all analyses, with weighting by the inverse probability of including each puerperae, a calibration to ensure that the distribution of the sampled mothers corresponded to the distribution of deliveries in the 606 hospitals in 2017, and using the design effect. All analyses were performed using SPSS software version 22.

The Human Research Ethics Committee of the Federal University of Maranhão and the Sérgio Arouca National School of Public Health approved the evaluation study on December 14, 2016. The Informed Consent Form (ICF) was read before the interview to all women and managers, and a copy was given to those who agreed to participate in the evaluation. All precautions were taken to ensure the privacy and confidentiality of the information.

Results

A total of 303 (2.9% 95% CI: 2.4%-3.4%) of the 10,539 live births had a gestational age fewer than 34 weeks at birth, 33.2% had GA less than 30 weeks, and 66.8% with GA between 30 and 33 weeks. Most women lived in the Northeast (37.3%) and Southeast (29.6%) regions of the country, self-reported brown (59.3%), and had secondary education and over (43.8%). One-fifth of women were adolescents (20.8%), 23.6% had no partner, and 43.3% were having their first birth. Most women (60.2%) did not plan the pregnancy, and 37.9% reported having sought more than one service for admission to childbirth. There were no significant differences in maternal characteristics according to GA at birth (Table 1).

In total, 6.3% (95% CI 3.7% -10.5%) of the total number of newborns with GA less than 34 weeks were admitted to hospitals with inappropriate neonatal services for gestational age at birth. Women residing in the midwestern macro-region (10%), aged between 30 and 34 years old (8.6%), black (8.7%), with less education than elementary school (12.1%), with three or more previous births (14.2%), living without a partner (9.7%), and with unplanned pregnancies (8.7%), had a higher prevalence of inappropriate birthplace (Table 2).

In the non-adjusted logistic regression, the highest likelihood of birth in an inappropriate place was observed in less educated women (OR=4.97 CI=1.25-19.76) and in those with higher parity (OR=5.68 CI=1.42-22.69), with a gradient in the associations, that is, the lower the education level and the greater the number of births, the greater the likelihood of birth in inappropriate services for gestational age. The gradient for schooling was maintained after adjusting for covariates, but with loss of statistical significance. The likelihood of birth in an inappropriate place in women with three or more previous births was increased after adjusting for the other variables (OR=8.28 95% CI 1.34-51.11). Women aged 35 years or older were less likely to have preterm birth in an inappropriate place (OR=0.13 CI=0.17-0.95) (Table 3).

Figure 1 shows the early outcomes of newborns up to the time of the interviews with women in the postpartum period, according to the gestational age ranges of less than 30 weeks and 30 to 33 weeks. Nine of the newborns with less than 30 weeks of gestation were born in maternity services without neonatal ICU. Of these, one died early, and eight had hospitalization records: two were transferred to other services of greater complexity and six were hospitalized under adapted conditions – of which two died. Thus, mortality in newborns with GA less than 30 weeks hospitalized in services not appropriate to their risk was 33.3%, while it was 5.9% in those hospitalized in appropriate services. Ten of the newborns with a gestational age of 30 to 34 weeks were born in services without UCINCo/UCINCa, with only one of them having hospitalization records made under adapted conditions, and the remaining nine probably remained in rooming-in with their mothers.

Discussion

In Brazil (DATASUS) and globally (Torchin et al.), 85% of preterm births are moderate to late, occurring in the gestational range of 32-36 weeks¹⁷17 Brasil. Ministério da Saúde (MS). Banco de dados do Sistema Único de Saúde-Datasus. [acessado 2020 Ago 10]. Disponível em http://www.datasus.gov.br
http://www.datasus.gov.br... ^,1818 Torchin H, Ancel PY. Epidemiology and risk factors of preterm birth. J Gynecol Obstet Biol Reprod 2016; 45(10):1213-1230.. In this study, using data form “Rede Cegonha” reference services, we observed a 2.9% rate of preterm birth with GA of less than 34 weeks. This result is similar to that found in a national survey conducted in the 2011-2012 period, where this proportion was 3.0%, equivalent to 74% of preterm births¹⁹19 Pereira APE, Leal MDC, Gama SGN, Domingues RMSM, Schilithz AOC, Bastos MH. Determinação da idade gestacional com base em informações do estudo Nascer no Brasil. Cad Saude Publica 2014; 30(Supl. 1):S59-S70.. Costa et al. evaluated information from SINASC for 2013 and found 1.0% of SUS births within the gestational age range below 32 weeks²⁰20 Costa MFS, Gomes Junior SC, Magluta C. Análise da distribuição dos nascimentos com marcadores de gravidade em maternidades com unidade de terapia intensiva neonatal no Sistema Único de Saúde. Cad Saúde Colet 2018; 26(2):125-130..

Several maternal (sociodemographic, obstetric, psychological, and genetic characteristics), environmental, and paternal factors have been associated with preterm births¹⁸18 Torchin H, Ancel PY. Epidemiology and risk factors of preterm birth. J Gynecol Obstet Biol Reprod 2016; 45(10):1213-1230.^,2121 Ayebare E, Ntuyo P, Malande OO, Nalwadda G. Maternal, reproductive and obstetric factors associated with preterm births in Mulago Hospital, Kampala, Uganda: a case control study. Pan African Medical Journal 2018; 30:272. Maternal characteristics of preterm and full-term newborns were not compared in this study. However, a higher proportion of preterm infants was observed in the Midwest, North, and Northeast regions, the least economically developed, and a lower proportion in the South and Southeast regions.

The proportion of adolescent mothers was also higher among preterm infants than in the total live births in the country (20.8% vs. 16.5%)²²22 Brasil. Ministério da Saúde (MS). Portal da Saúde: SINASC. [site da Internet] [acessado 2020 Ago 10]. Disponível em: ://portal.saude.gov.br/portal/svs/visualizar_texto.cfm?idtxt=2132339
://portal.saude.gov.br/portal/svs/visual... , similarly to other studies that point to a higher prevalence of preterm births in women of extreme age groups²³23 Gravena AAF, Paula MG, Marcon SS, Carvalho MDB, Pelloso SM. Idade materna e fatores associados a resultados perinatais. Acta Paulista de Enfermagem 2013; 26(2):130-135.^,2424 Nunes FBBF, Silva PC, Barbosa TLSM, Lopes MLH Silva EL. Influence of maternal age in perinatal conditions in live births of São Luís, Maranhão. Revista de Pesquisa: Cuidado é Fundamental Online 2020; 12:292-299.. The schooling level also differed from that observed for the total of preterm births in Brazil, with higher proportions among women with less than elementary education or with secondary education. Lower schooling, a factor related to greater social vulnerability, is associated with spontaneous preterm births⁷7 Leal MD, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RM, Dias MAB, Moreira ME, Gama SG. Prevalence and risk factors related to preterm birth in Brazil. Reprod Health 2016; 13(Supl. 3):127.. The higher proportion of women with complete secondary education or more may be due to a generational cohort effect since the proportion of pregnant women in advanced age was high, and these are generally more educated than adolescents. Concerning teenage pregnancy, a recent integrative review showed the influence of prenatal care and schooling level on the preterm birth , concluding that obstetric and fetal risks can be minimized if there is a support network directed at adolescents, who focus on reproductive, prenatal care, and social support²⁵25 Farias RV, Soares CFS, Araújo RS, Almeida VRS, Leitão DS, Santos JS, Santos LS, Nogueira SDA, Morais AC, Oliveira CBF. Gravidez na adolescência e o desfecho da prematuridade: uma revisão integrativa de literatura. Revista Eletrônica Acervo Saúde 2020; 56:3977.. A higher prevalence was also observed in non-white women, mostly brown and black women, the population with the most significant social vulnerability in the Brazilian context²⁶26 Oliveira KA, Araújo EM, Oliveira KA, Cassoti CA, Silva CAL, Santos DB. Associação entre raça/cor da pele e parto prematuro: revisão sistemática com meta-análise. Rev Saude Publica 2018; 52:26..

The proportion of women who reported having sought more than one service for admission to childbirth care (37.9%) was higher than that found in a previous national survey, which estimated 16.2% of pilgrimage²⁷27 Domingues RM, Dias MA, Schilithz AO, Leal MD. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reprod Health 2016; 13(Supl. 3):115.. Studies have reported association of pilgrimage with negative maternal²⁷27 Domingues RM, Dias MA, Schilithz AO, Leal MD. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reprod Health 2016; 13(Supl. 3):115.^,2828 Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, Brazilian Network for the Surveillance of Severe Maternal Morbidity study group. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth 2014; 14:159. and neonatal²⁹29 Lansky S, Lima Friche AA, Silva AA, Campos D, Azevedo Bittencourt SD, Carvalho ML, Frias PG, Cavalcante RS, Cunha AJ. Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care. Cad Saude Publica 2014; 30(Supl. 1):S1-15.^,3030 Leal MDC, Esteves-Pereira AP, Viellas EF, Domingues RMSM, Gama SGND. Prenatal care in the Brazilian public health services. Rev Saude Publica 2020; 54:08. outcomes because of delayed access to hospital care and to receiving adequate care. A possible explanation for our result is that the “Rede Cegonha’s” maternity hospitals are generally reference services in their municipalities/states, leading women to be admitted to these services after having sought the first service in a less complex one.

Our result of absence of association of pilgrimage with inadequate birthplace for preterm newborns is in line with this hypothesis, reflecting the search of pregnant women for more complex services within “Rede Cegonha”. Other studies, like the one conducted by Menezes et al.³¹31 Menezes DCS, Leite IC, Ischramm JMA, Lela MDC. Avaliação da peregrinação anteparto numa amostra de puérperas no Município do Rio de Janeiro, Brasil, 1999/2001. Cad Saude Publica 2006; 22(3):553-559., found no association between the antepartum pilgrimage and the risk of the pregnant woman at the time of hospitalization, which may indicate that the pilgrimage process may also occur in search of availability of places and not necessarily of resources adequate to gestational risk needs.

An indicator used to assess perinatal health in Europe is the percentage of birth of very preterm newborns in units without NICU³²32 Menezes DCS. Caracterização dos riscos gestacionais e avaliação da adequação da internação hospitalar e peregrinação anteparto em uma amostra de puérperas no município do Rio de Janeiro 1999 - 2001 [dissertação]. Rio de Janeiro: Fiocruz; 2004.. Belgium, France, and Germany had more than 75% of live births with GA less than 32 weeks in units with NICU³²32 Menezes DCS. Caracterização dos riscos gestacionais e avaliação da adequação da internação hospitalar e peregrinação anteparto em uma amostra de puérperas no município do Rio de Janeiro 1999 - 2001 [dissertação]. Rio de Janeiro: Fiocruz; 2004.^,3333 Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C. European indicators of health care during pregnancy, delivery and the postpartum period. Eur J Obstet Gynecol 2003; 111(Supl. 1):S53-S65.. A study carried out with puerperae attended at SUS in Rio de Janeiro highlights that 29% of high-risk puerperae had childbirth care in establishments without NICU³²32 Menezes DCS. Caracterização dos riscos gestacionais e avaliação da adequação da internação hospitalar e peregrinação anteparto em uma amostra de puérperas no município do Rio de Janeiro 1999 - 2001 [dissertação]. Rio de Janeiro: Fiocruz; 2004..

In this study, 6.3% of newborns with less than 34 gestational weeks were born in establishments with inappropriate neonatology services for their gestational age. As we only included in our study services located in a health region that had a “Rede Cegonha”³⁴34 Brasil. Ministério da Saúde (MS). Portaria nº 1.459, 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde, a Rede Cegonha. Diário Oficial da União 2011; 24 jun. action plan, which is a strategy for organizing the line of care for pregnant women and children up to the age of two, it should be assumed that our results are better than those carried out in hospitals not integrated to the “Rede Cegonha”.

A study that analyzed hospitalizations in neonatal services, using birth weight below 1,500g and Apgar score in the 5^th minute below 7 as severity markers, found that 38% of births with a severity marker occurred in establishments without Neonatal Intensive Care Unit. While the criteria adopted are different, some results, such as the highest rate of hospitalization in an appropriate place in the South and Southeast, are similar to our study²⁰20 Costa MFS, Gomes Junior SC, Magluta C. Análise da distribuição dos nascimentos com marcadores de gravidade em maternidades com unidade de terapia intensiva neonatal no Sistema Único de Saúde. Cad Saúde Colet 2018; 26(2):125-130..

In 2011-2012, only 39.3% of public hospitals had NICUs and data on UCINCo were not available ³⁵35 Bittencourt SDA, Gurgel RQ, Menezes MAS, Bstos LS, Leal MC. Neonatal care in Brazil: hospital structure and adequacy according to newborn obstetric risk. Paediatr Int Child Health 2015; 35(3):206-212.. On that occasion, the North, Northeast, and Midwest regions had the lowest proportions of services with NICUs, although they had similar prevalence of extreme preterm births³⁵35 Bittencourt SDA, Gurgel RQ, Menezes MAS, Bstos LS, Leal MC. Neonatal care in Brazil: hospital structure and adequacy according to newborn obstetric risk. Paediatr Int Child Health 2015; 35(3):206-212.. In this study, these same regions showed the highest hospitalization rates in inappropriate services according to gestational age at birth. While these differences were not statistically significant, probably due to the small sample size, they may point to inequalities in the distribution of neonatal care services. Survival and quality of life are higher for extremely preterm infants born in hospitals with NICU care services. In France, living in a distant location from services with a NICU reduced the likelihood of hospitalization in specialized services, even when adjusted for maternal and obstetric characteristics³⁶36 Pilkington H, Blondel B, Papiernik E, Cuttini M, Charreire H, Maier RF, Petrou S, Combier E, Künzel W, Bréart G, Zeitlin J. Distribution of maternity units and spatial access to specialised care for women delivering before 32 weeks of gestation in Europe. Health Place 2010; 16(3):531-538..

The finding of adapted hospitalizations of preterm newborns with less than 30 gestational weeks in “Rede Cegonha” services without NICU service is a reason for concern. Although the numbers are small, the mortality rate in these adapted hospitalizations was six times higher than that observed in hospitals with NICUs (33.3% vs. 5.9%). Deaths in non-adapted hospitalizations may indicate that births occurring in a place with an appropriate neonatal service for GA do not guarantee timely care³²32 Menezes DCS. Caracterização dos riscos gestacionais e avaliação da adequação da internação hospitalar e peregrinação anteparto em uma amostra de puérperas no município do Rio de Janeiro 1999 - 2001 [dissertação]. Rio de Janeiro: Fiocruz; 2004..

The highest proportion of births in an inappropriate place was observed in less educated women, with unplanned pregnancies and a higher number of previous births, although only parity had a significant association in the adjusted analysis. The association between lower schooling and an inappropriate place for the risk of the puerperae was described by Menezes, in which the likelihood of less-educated women to have their children in establishments without a Neonatal Unit was 30% greater³²32 Menezes DCS. Caracterização dos riscos gestacionais e avaliação da adequação da internação hospitalar e peregrinação anteparto em uma amostra de puérperas no município do Rio de Janeiro 1999 - 2001 [dissertação]. Rio de Janeiro: Fiocruz; 2004.. Low schooling, higher parity, and unplanned pregnancies are also associated with lower use of prenatal care services, with a higher proportion of women not attending prenatal care services or with late prenatal care initiation and fewer visits³⁷37 Viellas EF, Domingues RM, Dias MA, Gama SG, Theme Filha MM, Costa JV, Bastos MH, Leal MC. Prenatal care in Brazil. Cad Saude Publica 2014; 30(Supl. 1):S1-15.. A nationwide study also showed the association of women low schooling with pilgrimage to childbirth care³⁶36 Pilkington H, Blondel B, Papiernik E, Cuttini M, Charreire H, Maier RF, Petrou S, Combier E, Künzel W, Bréart G, Zeitlin J. Distribution of maternity units and spatial access to specialised care for women delivering before 32 weeks of gestation in Europe. Health Place 2010; 16(3):531-538.. Women with unplanned pregnancies, lower economic status and substandard quality care for childbirth and neonatal care also have a higher prevalence of postpartum depression³⁸38 Theme Filha MM, Ayers S, Gama SG, Leal M C. Factors associated with postpartum depressive symptomatology in Brazil: The Birth in Brazil National Research Study, 2011/2012. J Affect Disord 2016; 194:159-167.. In France, Zeitlin et al.³⁹39 Zeitlin J, Gwanfogbe CD, Delmas D, Pilkington H, Jarreau PH, Chabernaud JL, Bréart G, Papiernik E. Risk factors for not delivering in a level III unit before 32 weeks of gestation: results from a population-based study in Paris and surrounding districts in 2003. Paediatr Perinat Epidemiol 22(2):126-135. assessed the factors associated with the birth of extremely preterm infants in services without NICU care. The study identified that prematurity’s most significant risk often occurs in pregnant women that also have difficulty to access specialized services, deteriorating perinatal outcomes.

This study has some limitations. The first one refers to the exclusive use of gestational age to define the type of neonatal care service needed. Newborns with more than 30 gestational weeks may have required intensive care (NICU), but they were classified as “birth in an appropriate place” when they were born in establishments with UCINCo, which may have overestimated our findings of birth in an appropriate place. However, this limitation does not affect this study’s objective, which is to assess whether the birthplace of the newborn under 34 weeks was appropriate for his gestational age.

The method used to calculate gestational age is also a limitation. We used a specific algorithm to estimate the most accurate gestational age but errors may have occurred, which may explain, for example, our results of newborns with less than 30 gestational weeks without admission to an intensive care service and with favorable outcome. It is worth mentioning that we assessed the newborn’s outcome during the maternal interview, identifying neonatal deaths that occurred up to that moment. Some newborns may have died later during hospitalization, which may have underestimated unfavorable progress.

Finally, items related to the structure and care processes of the existing neonatal care services were not evaluated, and in these cases, the newborns may have been hospitalized in appropriate places according to their typology, but without appropriate operating conditions. Even in the face of these limitations, this study brings essential contributions to understanding the care flows and the factors associated with the place of birth of preterm newborns among the maternity hospitals affiliated with “Rede Cegonha”.

Conclusion

The prevalence of preterm births below 34 gestational weeks in the country is high, with significant regional and social differences. The proportion of preterm infants admitted to intensive or intermediate neonatal care services not appropriate for gestational age at birth was low but was associated with factors that indicate a greater social vulnerability of parturients. This situation shows that there are still inequalities in access to intensive and intermediate care for preterm newborns in the context of maternity hospitals linked to the “Rede Cegonha”.

We highlight, therefore, the importance of early identification of this group of women to ensure an adequate line of care throughout pregnancy, childbirth and postpartum, avoiding the emergence of adverse health outcomes. Specifically, at the time of hospital admission for childbirth care, the gestational age would allow the transfer of pregnant women to services with an appropriate structure to assist preterm newborns.

New studies should also investigate long-term outcomes of newborns hospitalized in inappropriate places for gestational age at birth, such as deaths, and assess neonatal services’ adequacy, ensuring that newborns are admitted to places appropriate to their gestational age and with adequate operating conditions.

For health management, this study’s findings confirm how urgent it is to invest in the health system and public policies geared to the quality of maternal and neonatal care in the maternity hospital units of “Rede Cegonha”.

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