Abstract

Introduction

The targets of the Sustainable Development Goals (SDGs) include the reduction of mortality in under-five children to less than 25 per 1,000 live births, reduction of neonatal mortality to less than 12 deaths per 1,000 live births, and elimination of avoidable deaths in newborns and under-five children, from 2016 to 2030 ¹1. GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1725-74.^,22. GBD 2016 Child Mortality Collaborators. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390:1084-150.. Before the deadline, Brazil reached the target of the Millennium Development Goals (MDGs) to reduce mortality in under-five children by two-thirds by 2015 ³3. Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, et al. Reproductive, maternal, neonatal and child health in the 30 years since the creation of the Unified Health System (SUS). Ciênc Saúde Colet 2018; 23:1915-28..

The same pattern was true in the city of Rio de Janeiro, Brazil (Departamento de Informática do Sistema Único de Saúde - DATASUS. Informações de saúde. Estatísticas vitais. http://www2.datasus.gov.br/DATASUS/index.php?area=0205, accessed on 09/Jul/2018), (Secretaria Municipal de Saúde do Rio de Janeiro. Sistemas de informação em saúde. http://tabnet.rio.rj.gov.br/, accessed on 30/Jun/2018). Although the under-five and neonatal mortality rates in the city of Rio de Janeiro were already below the targeted levels by 2016 (14.9 and 8.3 per thousand live births, respectively), the causes of death are still mostly avoidable (http://tabnet.rio.rj.gov.br/, accessed on 30/Jun/2018). The fact that other Latin American countries like Cuba and Costa Rica had under-five mortality rates in 2016 of 5.3 and 10.6 per thousand live births, respectively, reinforces the potential for further reduction of under-five mortality in Brazil ¹1. GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1725-74.^,22. GBD 2016 Child Mortality Collaborators. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390:1084-150..

Various Brazilian studies have shown that the principal causes of under-five death are avoidable by health innterventions ⁴4. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26:481-91.^,55. Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML, et al. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saúde Pública 2014; 30 Suppl 1:S192-207.^,66. Santos IS, Matijasevich A, Gorgot LRMR, Valle NCJ, Menezes AM. Óbitos infantis evitáveis nas coortes de nascimentos de Pelotas, Rio Grande do Sul, Brasil, de 1993 e 2004. Cad Saúde Pública 2014; 30:2331-43.^,77. Santos HG, Andrade SM, Silva AMR, Mathias TAF, Ferrari LL, Mesas AE. Mortes infantis evitáveis por intervenções do Sistema Único de Saúde: comparação de duas coortes de nascimentos. Ciênc Saúde Colet 2014; 19:907-16.^,88. França EB, Lansky S, Rego MAS, Malta DC, França JS, Teixeira R, et al. 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 Suppl 1:46-60.. In the Pelotas birth cohorts (Rio Grande do Sul State), the persistence of infant mortality rates from avoidable causes was attributed to maternal socioeconomic and biological disadvantages, associated with the increase in preterm births ⁶6. Santos IS, Matijasevich A, Gorgot LRMR, Valle NCJ, Menezes AM. Óbitos infantis evitáveis nas coortes de nascimentos de Pelotas, Rio Grande do Sul, Brasil, de 1993 e 2004. Cad Saúde Pública 2014; 30:2331-43..

Considering that prematurity and asphyxia at birth are complications heavily associated with neonatal deaths ⁷7. Santos HG, Andrade SM, Silva AMR, Mathias TAF, Ferrari LL, Mesas AE. Mortes infantis evitáveis por intervenções do Sistema Único de Saúde: comparação de duas coortes de nascimentos. Ciênc Saúde Colet 2014; 19:907-16.^,99. Oza S, Lawn JE, Hogan DR, Mathers C, Cousens SN. Neonatal cause-of-death estimates for the early and late neonatal periods for 194 countries: 2000-2013. Bull World Health Organ 2015; 93:19-28.^,1010. Almeida MF, Kawakami MD, Moreira LM, Santos RM, Anchieta LM, Guinsburg R. Early neonatal deaths associated with perinatal asphyxia in infants = 2500g in Brazil. J Pediatr (Rio J) 2017; 93:576-84., conditions at birth based on gestational age, birthweight, and five-minute Apgar score have been shown as markers of life-threatening conditions at birth. These markers, called pragmatic criteria, singly ¹¹11. Pileggi C, Souza JP, Cecatti JG, Faúndes A. Neonatal near miss approach in the 2005 WHO Global Survey Brazil. J Pediatr (Rio J) 2010; 86:21-6.^,1212. Kale PL, Mello Jorge MHP, Silva KS, Fonseca S C. Critérios pragmáticos da definição de near miss neonatal: um estudo comparativo. Rev Saúde Pública 2017, 51:111. or jointly comprise the clinical, laboratory, and management criteria ¹³13. Souza JP, Gülmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z; WHOMCS Research Group. The World Health Organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res 2011; 11:286.^,1414. Silva AAM, Leite AJM, Lamy ZC, Moreira MEL, Gurgel RQ, Cunha AJLA, et al. Morbidade neonatal near miss na pesquisa Nascer no Brasil. Cad Saúde Pública 2014; 30 Suppl 1:S182-91.^,1515. Pileggi-Castro C, Camelo Jr. JS, Perdoná GC, Mussi-Pinhata MM, Cecatti JG, Mori R, et al. Development of criteria for identifying neonatal near-miss cases: analysis of two WHO multicountry cross-sectional studies. BJOG 2014; 121 Suppl 1:110-8., various definitions of near miss, or severe neonatal morbidity: newborns with life-threatening conditions that survived the neonatal period. The occurrence of life-threatening conditions at birth and cases of neonatal near miss present increased risk of under-five death when compared to children born without life-threatening conditions. There are still few studies that have estimated the probability of death or survival in childhood among newborns with life-threatening conditions, or particularly among cases of neonatal near miss ¹⁶16. Kale PL, Fonseca SC, Saraceni V, Coeli CM, Silva KS, Barbeiro FMS, Torres TG. Ameaça à vida, near miss neonatal, mortalidade e sobrevida na infância: uma análise de coortes de nascidos vivos no Município do Rio de Janeiro, RJ, Brasil. In: III Convención Internacional de Salud Pública, 2018. http://convencionsalud2018.sld.cu/index.php/connvencionsalud/2018/paper/viewPaper/385.
http://convencionsalud2018.sld.cu/index.... .

This study estimated the burden of life-threatening conditions at birth, neonatal near miss, and mortality, with an emphasis on avoidable causes, as well as under-five survival, in live birth cohorts in the city of Rio de Janeiro, from 2012 to 2016.

Methods

This was a retrospective cohort study of singleton liveborn children living in the city of Rio de Janeiro from 2012 to 2016 (n = 426,867). We opted not to include newborns from multiple pregnancies since they present differentiated morbidity and mortality risks. The study population’s maximum follow-up period was five incomplete years after birth (starting on January 1, 2012, and ending on December 31, 2016). Five-year follow-up was only possible for live births from the 2012 cohort.

The data sources were the Brazilian Information System on Live Birth (SINASC) and the Brazilian Mortality Information System (SIM) of the Rio de Janeiro Municipal Health Department. The birth and death databases were initially linked by the number on the Certificate of Live Birth in the two databases, and in case of missing information in this field, probabilistic linkage was used. The proportion of linked death and birth records was 85.7%.

Newborns were classified as presenting life-threatening conditions if they met at least one of the pragmatic criteria for neonatal near miss ¹⁴14. Silva AAM, Leite AJM, Lamy ZC, Moreira MEL, Gurgel RQ, Cunha AJLA, et al. Morbidade neonatal near miss na pesquisa Nascer no Brasil. Cad Saúde Pública 2014; 30 Suppl 1:S182-91.: birthweight less than 1,500g, gestational age less than 32 weeks, and five-minute Apgar less than seven. Newborns with life-threatening conditions that survived the neonatal period (0 to 27 days) were classified as cases of neonatal near miss. The analysis excluded 0.3% of records with inconsistencies between birthweight and gestational age.

Deaths from zero to five incomplete years were classified according to the brazilian list of avoidable causes, consisting of three groups of causes of death: avoidable, unclearly avoidable, and ill-defined. The group of avoidable causes consists of seven subcategories according to the type of intervention ¹⁷17. Malta DC, Sardinha LMV, Moura L, Lansky S, Leal MC, Szwarcwald CL, et al. Atualização da lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2010; 19:173-6..

We calculated the proportion of liveborn infants with life-threatening conditions at birth. For the 2012 cohort, the disease burden of newborns with life-threatening conditions and survivors of the neonatal period was measured by the neonatal near miss rate (NNMR: number of neonatal near miss cases per 1,000 live births). We calculated the ratio between deaths and cases of neonatal near miss.

The risks of death (probability of death), both total and according to life-threatening conditions at birth, were calculated by the actuarial method, adjusted for losses ¹⁸18. Gordis L. The natural history of disease: ways of expressing the prognosis. In: Gordis L, editor. Epidemiology. 5th Ed. Philadelphia: W. B. Saunders Elsevier 2014. p. 116-37., by age groups, per thousand: neonatal mortality (quotient between deaths from 0 to 27 days and number of live births, or life table root) and post-neonatal mortality (quotient between deaths from 28 to 364 days and the number of live births), with survivors of the previous age bracket who were one, two, three, and four complete years old. The relative risk of death according to life-threatening conditions at birth was calculated by age.

We calculated the infant mortality rate (IMR), neonatal mortality rate (NMR), and under-five mortality rate (UFMR) per 1,000 live births only for the 2012 birth cohort (which presented five incomplete years of follow-up). Considering all the birth cohorts as a single dynamic cohort with different follow-up times from 2012 to 2016, we calculated the NMR, IMR, and UFMR per 100,000 person-days. The under-five mortality rate was also calculated according to the Brazilian list of avoidable causas (three groups), both total and comparing live births with and without life-threatening conditions. The principal specific causes of death were described (groupings from the International Classification of Diseases - 10^th revision - ICD-10), by groups and subgroups of Brazilian list of avoidable causas. The attributable risk (AR) or etiological fraction was calculated according to life-threatening conditions for each group of avoidable causes, and the proportional attributable fraction (%AR) from life-threatening conditions, considering the under-five mortality rate per 100,000 person-days. Considering that the data were obtained from health information systems with excellent coverage in the state of Rio de Janeiro (DATASUS. Consolidação do Sistema de Informações sobre Nascidos Vivos - 2011. http://tabnet.datasus.gov.br/cgi/sinasc/Consolida_Sinasc_2011, accessed on 20/Mar/2017), (DATASUS. Consolidação do Sistema de Informações sobre Mortalidade - 2011. http://tabnet.datasus.gov.br/cgi/sim/Consolida_Sim_2011.pdf, accessed on 20/Mar/2017) and thus representative of the population, we can infer that the %AR can be interpreted as the population %AR ¹⁹19. Szklo M, Javier Nieto F. Measures of association between exposures and outcomes. In: Szklo M , Javier Nieto F , editors. Epidemiology: byond the basics. 3rd Ed. Sudbury: Jones & Bartlet Learning; 2014. p. 79-105..

The Kaplan-Meier method was used for analysis of the survival curves ¹⁸18. Gordis L. The natural history of disease: ways of expressing the prognosis. In: Gordis L, editor. Epidemiology. 5th Ed. Philadelphia: W. B. Saunders Elsevier 2014. p. 116-37. of liveborn infants with and without life-threatening conditions. Log-rank statistic was used to test the difference between the survival curves.

The study is an integral part of the research project Neonatal Near Miss, Deaths, and Under-Five Survival: Analysis of Live Birth Cohorts in the City of Rio de Janeiro, approved by the Institutional Review Boards of the Institute of Studies in Collective Health, Federal University of Rio de Janeiro (protocol n. 2.105.885), and the Rio de Janeiro Municipal Health Department (protocol n. 2.218.098).

Results

The birth cohorts totaled 425,505 live births. We classified 419,357 live births according to with versus without lifethreatening conditions at birth, of which 2.2% presented at least one pragmatic criterion of risk of death, and 3,820 evolved to under-five death, corresponding to a rate of 0.01 per 1,000 person-days (Table 1). The under-five mortality rate, infant mortality rate, neonatal mortality rate, and neonatal near miss rate for the 2012 birth cohort were, respectively, 12.0, 10.6, 6.7, and 20.1 per 1,000 live births. The ratio between near miss and neonatal deaths was 3:1.

Table 2 shows the risks of death (probabilities of death adjusted for losses to follow-up) according to life-threatening condition per 1,000 survivors of the previous age bracket. Newborns with life-threatening conditions presented higher risk of death than those without life-threatening conditions at all ages, especially in the neonatal period, and a reduction of 18.6% in the probability of survival up to five incomplete years. Independently of history of life-threatening conditions, the risk of death decreased with age (Table 2).

Among deaths of under-five children, 61%, 34%, and 4% were due to avoidable causes, unclearly avoidable causes, and ill-defined causes, respectively. The pattern in the distribution of causes in the three major groups of Brazilian list of avoidable causas is repeated in the presence or absence of life-threatening conditions at birth, although the percentage values for the unclearly avoidable and ill-defined groups were higher in newborns without life-threatening conditions, while avoidable causes showed a higher percentage in the group with life-threatening conditions (Table 3). Considering only the subgroups of avoidable causes, there was a predominance of causes that were reducible by adequate prenatal care among newborns with life-threatening conditions and reducible by adequate diagnosis and treatment among newborns without life-threatening conditions.

The principal specific causes of death in the group of causes reducible by adequate prenatal care were maternal hypertensive disorders (P00.0 ICD-10) for children with life-threatening conditions at birth and maternal renal and urinary tract diseases (ICD-10 P00.1) for those without life-threatening conditions (24.9% live births with and 18.4% without live-threatening conditions) (Table 3).

In the groups of causes reducible by adequate intrapartum care, 31.5% of the deaths of children without life-threatening conditions were due to neonatal meconium aspiration (P24.0 ICD-10), followed by neonatal aspiration, unspecified (P24.9), while two causes tied for third, intrauterine hypoxia (P20.9 ICD-10: 11%) and birth asphyxia (P21.9 ICD-10: 11%). The life-threatening conditions at birth were predominantly birth asphyxia (P21.9 ICD-10: 19.4%) and neonatal meconium aspiration (P24.0 ICD-10: 18.8%) (Table 3).

Causes reducible by immunoprevention appeared less frequently among the subgroups of avoidable causes, and the specific causes were pertussis and tuberculosis, independently of history of life-threatening conditions at birth (Table 3).

In the other groups of avoidable causes, there was no difference in the order of the principal causes according to history of life-threatening conditions at birth. Bacterial sepsis of newborn (P36 ICD-10) was the principal cause of death reducible by adequate care for the neonate (Table 3).

In addition, history of life-threatening conditions did not interfere in the order of the principal clearly avoidable and ill-defined causes of death. The former were predominantly congenital malformations (83.8% and 69.6% among those born with and without life-threatening conditions, respectively), mainly congenital cardiopathies (Q20 to Q26 ICD-10: 17.1% versus 37.1%). Other ill-defined causes, unspecified (R99 ICD-10: 77.3% versus 74.8%) were the main diagnoses in the group of ill-defined causes (Table 3).

As for risk of death, independently of the subgroup of avoidable causes, under-five mortality rates were higher among newborns with life-threatening conditions at birth when compared to those without life-threatening conditions (Figure 1). The under-five mortality rates from avoidable and unclearly avoidable causes were lower and close to those for infants without life-threatening conditions at birth.

The absolute difference between the under-five mortality rates per thousand person-days according to history of life-threatening conditions at birth was 14.8 for avoidable causes, 5.6 for unclearly avoidable causes, and 0.3 for ill-defined causes. The attributable risk of under-five death from avoidable causes with history of life-threatening conditions was 97.6%, that is, for every 100 avoidable deaths among under-five children who were born with life-threatening conditions, 98 would be avoidable if this condition at birth had been prevented in the population base.

Figure 2 shows the survival curves. Survival up to five years of age was lower among children with life-threatening conditions at birth when compared to those without life-threatening conditions (p < 0.00001). The largest reduction in survival occurred close to birth, approximately 14%, considering only the neonatal period. Importantly, after 27 days of age, infants with life-threatening conditions at birth, cases of near miss, still showed a 4.6% reduction in survival, especially in the first two years of life.

Discussion

A history of life-threatening conditions at birth reduced by 19% the probability of survival up to five incomplete years, and the principal causes of death were reducible by interventions by the Brazilian Unified National Health System (SUS).

The deaths in under-five children were mostly concentrated in early infancy, and there was thus a larger reduction in survival at earlier ages. The neonatal period is the most vulnerable period for infant deaths, accounting for approximately 55% of deaths up to five years of age in Brazil in 2015 ¹⁰10. Almeida MF, Kawakami MD, Moreira LM, Santos RM, Anchieta LM, Guinsburg R. Early neonatal deaths associated with perinatal asphyxia in infants = 2500g in Brazil. J Pediatr (Rio J) 2017; 93:576-84.. This concentration in the neonatal period is expected when infant mortality decreases, as in developed countries ²2. GBD 2016 Child Mortality Collaborators. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390:1084-150.. In addition, the relationship between the relative risk of death by history of life-threatening conditions according to age at death indicates biological vulnerabilities in relation to life-threatening conditions at birth and age at death.

In the live birth cohorts in the city of Rio de Janeiro, deaths in under-five children were predominantly from avoidable causes. The highest concentration of deaths in the first month of life underlines the relevance of factors associated with the gestation, labor and delivery, and postpartum period for reducing under-five mortality ⁸8. França EB, Lansky S, Rego MAS, Malta DC, França JS, Teixeira R, et al. 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 Suppl 1:46-60.. Causes reducible by improved prenatal care are expected due to the higher frequency of very low birthweight (< 1,500g) and very premature newborns (< 32 weeks gestational age), which are pragmatic criteria for defining life-threatening conditions and are totally or partially avoidable by qualified prenatal care ⁵5. Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML, et al. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saúde Pública 2014; 30 Suppl 1:S192-207.^,2020. Silveira MF, Santos IS, Barros AJD, Matijasevich A, Barros FC, Victora CG. Aumento da prematuridade no Brasil: revisão de estudos de base populacional. Rev Saúde Pública 2008; 42:957-64..

Birthweight less than 1,500g was strongly associated with neonatal death in Brazil ⁷7. Santos HG, Andrade SM, Silva AMR, Mathias TAF, Ferrari LL, Mesas AE. Mortes infantis evitáveis por intervenções do Sistema Único de Saúde: comparação de duas coortes de nascimentos. Ciênc Saúde Colet 2014; 19:907-16.. In the world, complications of preterm birth accounted for 15.4% of deaths in under-five children and 10.5% of intrapartum complications in 2013 ²¹21. Victora CG. Causes of child deaths: looking to the future. Lancet 2015; 385:398-9.. Neonatal survivors with very low birthweight and low gestational age show high risk of neurodevelopmental abnormalities ²²22. Cejas G, Gómez Y, Roca MC, Domínguez F. Neurodevelopment of very low birth weight infants in the first two years of life in a Havana tertiary care hospital. MEDICC Rev 2015; 17:14-7.. Premature newborns, especially those with less than 32 weeks gestational age, have a higher risk of neonatal death, which persists in the post-neonatal period. There is also an important risk of long-term neurodevelopmental impairment, low stature, and noncommunicable conditions ²³23. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every newborn: progress, priorities, and potential beyond survival. Lancet 2014; 384:189-205.. The third pragmatic criterion in the definition of life-threatening conditions, a five-minute Apgar score less than seven, indicative of asphyxia, relates essentially to conditions of intrapartum and neonatal care ⁵5. Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML, et al. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saúde Pública 2014; 30 Suppl 1:S192-207.. Among Brazilian neonates with low risk of death, perinatal asphyxia contributed to 40% of all neonatal deaths from 2005 to 2010 ¹⁰10. Almeida MF, Kawakami MD, Moreira LM, Santos RM, Anchieta LM, Guinsburg R. Early neonatal deaths associated with perinatal asphyxia in infants = 2500g in Brazil. J Pediatr (Rio J) 2017; 93:576-84.. In the current study, among newborns with life-threatening conditions, asphyxia and intrauterine hypoxia were the second cause (reducible by adequate neonatal care) and third cause (reducible by adequate intrapartum care) of avoidable death. In this sense, the definition of life-threatening conditions, based on the presence of at least one of the pragmatic criteria, was reflected in the mortality profile by groups and subgroups of avoidable causes, but had little effect on the ranking of specific causes. The differences found here relate more to the magnitude of deaths.

In the current study, among children born with life-threatening conditions, the predominant causes were reducible by adequate prenatal and intrapartum care. Maternal hypertensive disorders were the principal causes of death reducible by adequate prenatal care, independently of history of life-threatening conditions at birth. In the decade prior to the current study, there was an upward trend in the infant mortality rate reducible by adequate prenatal care, partly due to maternal hypertensive disorders, in a study in Londrina, Paraná State, Brazil ⁷7. Santos HG, Andrade SM, Silva AMR, Mathias TAF, Ferrari LL, Mesas AE. Mortes infantis evitáveis por intervenções do Sistema Único de Saúde: comparação de duas coortes de nascimentos. Ciênc Saúde Colet 2014; 19:907-16.. Shortcomings in prenatal care related to the management of diseases have been documented in the city of Rio de Janeiro ²⁴24. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saúde Pública 2012; 28:425-37.^,2525. Vettore MV, Dias M, Domingues RMSM, Vettore MV, Leal MD. Cuidados pré-natais e avaliação do manejo da hipertensão arterial em gestantes do SUS no Município do Rio de Janeiro, Brasil. Cad Saúde Pública 2011; 27:1021-34. and are the principal determinants of avoidable deaths in the state of Rio de Janeiro ⁸8. França EB, Lansky S, Rego MAS, Malta DC, França JS, Teixeira R, et al. 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 Suppl 1:46-60..

The deaths of under-five children without life-threatening conditions at birth featured causes reducible by adequate health promotion and diagnostic measures, related to contextual factors, most prevalent in the post-neonatal period. Although the principal specific causes are common to children both with and without life-threatening conditions, competing risks of death in the neonatal period (which are more frequent in children with life-threatening conditions at birth) may partly explain these results.

Pertussis and tuberculosis, immune-preventable causes, are still present among deaths of under-five children. As in other subgroups of avoidable causes, they reflect gaps in the healthcare provided to under-five children ⁴4. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26:481-91..

Congenital cardiopathies were the principal diagnoses in the group of unclearly avoidable causes of death in the current study. In the state of Rio de Janeiro (2006-2010), and among the infant deaths with congenital malformations, 39% presented congenital cardiopathies ²⁶26. Catarino CF, Gomes MASM, Gomes Junior SCS, Magluta C. Registros de cardiopatia congênita em crianças menores de um ano nos sistemas de informações sobre nascimento, internação e óbito do Estado do Rio de Janeiro, 2006-2010. Epidemiol Serv Saúde 2017; 26:535-43.. With improvements in healthcare during childhood, for example, congenital malformations can be expected to gain proportionally greater importance both in the neonatal period and from 1 to 59 months of age ²⁷27. Li Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet 2016; 388:3027-35.. In Brazil, congenital anomalies ranked second among causes of death in under-five children in 2015 and were the leading cause of death in the states of the South, Central, and Southeast (except for Minas Gerais and Goiás) ⁸8. França EB, Lansky S, Rego MAS, Malta DC, França JS, Teixeira R, et al. 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 Suppl 1:46-60..

The impact of the prevention of life-threatening conditions at birth can reduce by up to 97.6% the avoidable deaths in under-five children in the city of Rio de Janeiro, assuming a causal relationship and absence of confounding (http://tabnet.datasus.gov.br/cgi/sim/Consolida_Sim_2011.pdf). In absolute numbers, this means that 1,653 under-five children would not have died if they had been born without life-threatening conditions.

The estimated survival of cases of neonatal near miss, presented in a previous publication ¹⁶16. Kale PL, Fonseca SC, Saraceni V, Coeli CM, Silva KS, Barbeiro FMS, Torres TG. Ameaça à vida, near miss neonatal, mortalidade e sobrevida na infância: uma análise de coortes de nascidos vivos no Município do Rio de Janeiro, RJ, Brasil. In: III Convención Internacional de Salud Pública, 2018. http://convencionsalud2018.sld.cu/index.php/connvencionsalud/2018/paper/viewPaper/385.
http://convencionsalud2018.sld.cu/index.... , raise the discussion on vulnerability and the need for care for these children and social support for their families. The extension of survival analysis up to four complete years based on history of life-threatening conditions at birth emphasizes that the prevention of life-threatening conditions at birth is indispensable for reducing life-course morbidity and mortality.

The burden of severe disease in neonates, measured in the current study as the population-based neonatal near miss rate, was 20.1 per 1,000 live births. There are no publications with the rate’s population-based calculation to make a direct comparison with our results. In the maternity hospital with the most births in the city of Rio de Janeiro, and which almost exclusively serves the local birthing demand, the neonatal near miss rate by place of birth and based on the same pragmatic definition of near miss as in our study was 28.6 per thousand live births in 2011 ¹²12. Kale PL, Mello Jorge MHP, Silva KS, Fonseca S C. Critérios pragmáticos da definição de near miss neonatal: um estudo comparativo. Rev Saúde Pública 2017, 51:111..

The study’s strengths include the exclusive use of pragmatic criteria in the definition of life-threatening conditions and neonatal near miss and the calculation of indicators based on this definition in the population base (live birth cohorts by mother’s place of residence), thus potentially assisting in monitoring maternal-child health in the city. The information system’s quality has improved in Brazil, particularly in the SINASC ²⁸28. Oliveira MM, Andrade SSCA, Dimech GS, Oliveira JCG, Malta DC, Rabello Neto DL, et al. Avaliação do Sistema de Informações sobre Nascidos Vivos. Brasil, 2006 a 2010. Epidemiol Serv Saúde 2015; 24:629-40.^,2929. Frias PG, Szwarcwald CL, Lira PIC. Avaliação dos sistemas de informações sobre nascidos vivos e óbitos no Brasil na década de 2000. Cad Saúde Pública 2014; 30:2068-80.. The SIM still presents some deficiencies, but the database linkage qualifies the data and contributes to the study of infant mortality ³⁰30. Maia LTS, Souza WV, Mendes ACG. A contribuição do linkage entre o SIM e SINASC para a melhoria das informações da mortalidade infantil em cinco cidades brasileiras. Rev Bras Saúde Mater Infant (Online) 2015; 15:57-66.^,3131. Maia LTS, Souza WV, Mendes ADCG, Silva AGSD. Uso do linkage para a melhoria da completude do SIM e do SINASC nas capitais brasileiras. Rev Saúde Pública 2017; 51:112.. In the current study, besides mortality, it was possible to assess the impact of the prevention of life-threatening conditions at birth on the mortality rates in under-five children. However, the lack of linkage of some pairs, particularly for deaths from one to four years of age, may have underestimated the under-five mortality rate. Mandatory recording of the number from the Certificate of Live Birth on the Death Certificate exclusively for infant deaths (under one year of age) decreases the odds of deterministic linkage according to the number on the Certificate of Live Birth. The quality of certification of the underlying cause is important for ensuring greater trustworthiness in the classification of deaths according to the Brazilian list of avoidable causes. In this sense, investigation of deaths by health services is a good strategy, but it does not extend to deaths from one to four years of age and sometimes may also fail to reach all infant deaths. In the city of Rio de Janeiro, the proportion of infant deaths that are investigated has increased steadily, reaching 95.5% in 2016 ³²32. Secretaria Municipal de Saúde do Rio de Janeiro. Análise da situação de saúde - dados vitais. indicadores de saúde de residentes no Município do Rio de Janeiro 2010-2017. http://www.rio.rj.gov.br/dlstatic/10112/7629558/4208473/IndicadoresNascimentoeMortalidadeMRJ_2010_2017_MRJ.pdf (acessado em 18/Jan/2018).
http://www.rio.rj.gov.br/dlstatic/10112/... .

Considering the profile of avoidable causes among newborns with life-threatening conditions, one can infer that the process that led to death is similar to that which led to the occurrence of near miss. This process can be prevented, at least partially, by improving prenatal care. The reduction in prematurity is still a challenge, but the control of hypertensive, metabolic, and infectious diseases during prenatal care can help reduce morbidity and mortality in the infant population in Rio de Janeiro.

Acknowledgments

C. M. Coeli holds a research productivity scholarship from the Brazilian National Research Council (CNPq) (305545/2015-9) and the Rio de Janeiro State Research Foundation (FAPERJ - E-26-200.03/2019).

References

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