ABSTRACT:

Objective:

To estimate trends of fetal (FMR) and neonatal (NMR) mortality rates due to avoidable causes and maternal education in the city of Rio de Janeiro (2000–2018).

Methods:

Ecological time series study. Mortality and Live Birth Information System Data. The List of Avoidable Causes of Death Due to Interventions of the Brazilian Health System was used for neonatal deaths and an adaptation for fetal deaths, according to maternal education indicators (low <4 and high ≥12, years of study). Joinpoint regression models were used to estimate trends in FMR, based on one thousand births, and NMR, based on one thousand live births.

Results:

FMR decreased from 11.0 to 9.3% and NMR from 11.3 to 7.8% (2000/2018). In 2006, FMR (10.5%) exceeded NMR (9.0%), remaining higher. From 2000 to 2018, the annual decrease of FMR was 0.8% (2000 to 2018) and of NMR, 3.8% until 2007, decreasing to 1.1% by 2011; from then on, it remained stable. Avoidable causes, especially those reducible by adequate prenatal care, showed higher rates. Both FMR and NMR for low-education women were higher than those for the high-education level, the difference being much more pronounced for FMR, and at the end of the period: low- and high-education FMR were respectively 16.4 and 4.5% (2000) and 48.5 and 3.9% (2018), and for NMR, 18.2 and 6.7% (2000) and 28.4 and 5.0% (2018).

Conclusion:

The favorable trend of decreasing mortality was not observed for children of mothers with low education, revealing inequalities. The causes were mostly avoidable, being related to prenatal care and childbirth.

Keywords
Fetal mortality; Infant mortality; Time series studies; Underlying cause of death; Educational status; Health inequality monitoring

INTRODUCTION

Worldwide, there was a reduction in neonatal mortality rate (NMR), from 37 to 18 deaths per thousand live births (LB) between 1990 and 2018¹1. Fundo de Emergência Internacional das Nações Unidas para a Infância (UNICEF). Levels and Trends in the level of child mortality [Internet]. UNICEF; 2019 [accessed on Jun. 15, 2020]. Available at: https://www.unicef.org/reports/levels-and-trends-child-mortality-report-2019
https://www.unicef.org/reports/levels-an... .

In Brazil, between 1990 and 2015, the decrease was 59%, going from 23.1 to 9.5 neonatal deaths per thousand LB²2. Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, et al. Saúde reprodutiva, materna, neonatal e infantil nos 30 anos do Sistema Único de Saúde (SUS). Ciên Saúde Coletiva 2018; 23(6): 1915-28. http://doi.org/10.1590/1413-81232018236.03942018
http://doi.org/10.1590/1413-81232018236.... . In 2016, there was a slight increase, and in 2017, a decrease of 1.7% compared to the previous year³3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Mortalidade infantil e em menores de 5 anos: risco ao nascer. In: Brasil. Ministério da Saúde. Saúde Brasil 2019: uma análise de situação de saúde com enfoque nas doenças imunopreveníveis e na imunização. Brasília: Ministério da Saúde; 2019. p. 29-70.. Inequality in the decline between regions was dependent on the initial magnitude of NMR³3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Mortalidade infantil e em menores de 5 anos: risco ao nascer. In: Brasil. Ministério da Saúde. Saúde Brasil 2019: uma análise de situação de saúde com enfoque nas doenças imunopreveníveis e na imunização. Brasília: Ministério da Saúde; 2019. p. 29-70.. In the state of Rio de Janeiro and in the capital, the rates were lower, respectively 13.6 and 11.2 in 2000 and 8.4 and 7.8 in 2018 per thousand LB, resulting in smaller decreases (38 and 30.3%)⁴4. Estado do Rio de Janeiro. Secretaria Estadual de Saúde. Informações de Saúde. Indicadores de Mortalidade. Taxas de mortalidade infantil e perinatal [Internet]. Rio de Janeiro: Secretaria Estadual de Saúde [accessed on Jul. 15, 2020]. Available at: http://sistemas.saude.rj.gov.br/tabnetbd/dhx.exe?taxas/sim_sinasc_taxas_mortalidade_infantil.def
http://sistemas.saude.rj.gov.br/tabnetbd... .

Parallel to neonatal deaths, fetal deaths reflect maternal morbidities and problems with prenatal care and childbirth. Until recently, these deaths were considered invisible, receiving little attention from researchers and managers⁵5. Lansky S. Mortalidade fetal: mortes invisíveis e evitáveis. In: Bittencourt S, Dias M, Duarte M, editores. Vigilância do Óbito Materno, Infantil e Fetal e Atuação em Comitês de Mortalidade. Rio de Janeiro: Fiocruz; 2013. v. 1. p. 123-33.^–77. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths; rates, risk factors, and acceleration towards 2030. Lancet 2016; 387(10018): 587-603. https://doi.org/10.1016/S0140-6736(15)00837-5
https://doi.org/10.1016/S0140-6736(15)00... . The fact that neonatal and fetal deaths share maternal causes justifies the study of both conditions to support planning, management and evaluation of health policies and measures for women and newborns⁵5. Lansky S. Mortalidade fetal: mortes invisíveis e evitáveis. In: Bittencourt S, Dias M, Duarte M, editores. Vigilância do Óbito Materno, Infantil e Fetal e Atuação em Comitês de Mortalidade. Rio de Janeiro: Fiocruz; 2013. v. 1. p. 123-33.^,66. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health 2016; 4(2): e98-e108. https://doi.org/10.1016/S2214-109X(15)00275-2
https://doi.org/10.1016/S2214-109X(15)00... . In the case of fetal deaths, studies have identified the need for specific interventions in prenatal and childbirth care⁵5. Lansky S. Mortalidade fetal: mortes invisíveis e evitáveis. In: Bittencourt S, Dias M, Duarte M, editores. Vigilância do Óbito Materno, Infantil e Fetal e Atuação em Comitês de Mortalidade. Rio de Janeiro: Fiocruz; 2013. v. 1. p. 123-33..

The most recent global estimate for fetal deaths was 2.6 million in 2015, corresponding to a fetal mortality rate (FMR) of 18.5 deaths per thousand births⁶6. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health 2016; 4(2): e98-e108. https://doi.org/10.1016/S2214-109X(15)00275-2
https://doi.org/10.1016/S2214-109X(15)00... . It is worth recalling that this rate, for international comparison, only includes stillbirths with a weight ≥1000 g or gestational age ≥28 weeks. Blencowe et al.⁶6. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health 2016; 4(2): e98-e108. https://doi.org/10.1016/S2214-109X(15)00275-2
https://doi.org/10.1016/S2214-109X(15)00... identified NMR and the prevalence of low weight, besides geographical location, as predictors of fetal mortality. The gross domestic product, the average number of years of maternal education and the number of prenatal visits were protective. Because of the relevance of fetal deaths and their slower reduction compared to neonatal deaths, worldwide initiatives have started to include their prevention⁶6. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health 2016; 4(2): e98-e108. https://doi.org/10.1016/S2214-109X(15)00275-2
https://doi.org/10.1016/S2214-109X(15)00... .

National estimates of FMR time trends from 2000 to 2016 showed stationary values (around 5 per thousand births) and large regional differences⁸8. Barros PS, Aquino ÉC, Souza MR. Mortalidade fetal e os desafios para a atenção à saúde da mulher no Brasil Rev Saúde Pública 2019; 53: 12. https://doi.org/10.11606/S1518-8787.2019053000714
https://doi.org/10.11606/S1518-8787.2019... . Stability was reproduced among the causes of Chapter XVI, except for the Northeast. Fetal deaths predominated between the 28th and 36th weeks of gestation, with an increasing trend, except in the South⁸8. Barros PS, Aquino ÉC, Souza MR. Mortalidade fetal e os desafios para a atenção à saúde da mulher no Brasil Rev Saúde Pública 2019; 53: 12. https://doi.org/10.11606/S1518-8787.2019053000714
https://doi.org/10.11606/S1518-8787.2019... .

Since 2000, infant deaths have been mostly close to birth, and their main causes have been related to prenatal, childbirth and newborn care²2. Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, et al. Saúde reprodutiva, materna, neonatal e infantil nos 30 anos do Sistema Único de Saúde (SUS). Ciên Saúde Coletiva 2018; 23(6): 1915-28. http://doi.org/10.1590/1413-81232018236.03942018
http://doi.org/10.1590/1413-81232018236.... . Intersectoral social policies, such as wealth distribution and Bolsa Família (family conditional cash transfer program), maternal and child health policies, such as the National Program for the Humanization of Delivery and Birth and the Kangaroo Method, increased maternal education, reduction in fertility and universalized assistance with the Unified Health System (SUS) have contributed to the decrease in infant mortality and reduction of inequalities²2. Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, et al. Saúde reprodutiva, materna, neonatal e infantil nos 30 anos do Sistema Único de Saúde (SUS). Ciên Saúde Coletiva 2018; 23(6): 1915-28. http://doi.org/10.1590/1413-81232018236.03942018
http://doi.org/10.1590/1413-81232018236.... . It is noteworthy, however, that the causes of infant and neonatal death are mostly avoidable by the effective action of health services³3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Mortalidade infantil e em menores de 5 anos: risco ao nascer. In: Brasil. Ministério da Saúde. Saúde Brasil 2019: uma análise de situação de saúde com enfoque nas doenças imunopreveníveis e na imunização. Brasília: Ministério da Saúde; 2019. p. 29-70.^,99. Malta DC, Prado RRD, Saltarelli RMF, Monteiro RA, Souza MFM, Almeida MF. Mortes evitáveis na infância, segundo ações do Sistema Único de Saúde, Brasil. Rev Bras Epidemiol 2019; 22: e190014. https://doi.org/10.1590/1980-549720190014
https://doi.org/10.1590/1980-54972019001... .

Between 2013 and 2016, in Brazil, 127,330 fetal deaths (31,833 deaths/year) were registered, a total higher than that of neonatal deaths, i.e., 105,106 (26,276/year)¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75.. The most common underlying causes were fetal death of unspecified cause (21.5%) and unspecified intrauterine hypoxia (15%), showing gaps in knowledge¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75.. Of the total, 17.1% had a weight ≥2500 g and occurrence at term. The occurrence of death in fetuses and newborns weighing ≥2500 g and/or at term warns of a potentially avoidable death³3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Mortalidade infantil e em menores de 5 anos: risco ao nascer. In: Brasil. Ministério da Saúde. Saúde Brasil 2019: uma análise de situação de saúde com enfoque nas doenças imunopreveníveis e na imunização. Brasília: Ministério da Saúde; 2019. p. 29-70.^,1010. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75.. In the case of fetal deaths, it can still suggest problems in recording vital statistics¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75..

Maternal education has been adopted as a measure of socioeconomic position¹¹11. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G. Indicators of socioeconomic position (part 1). J Epidemiol Community Health 2006; 60: 7-12. https://doi.org/10.1136/jech.2004.023531
https://doi.org/10.1136/jech.2004.023531... to assess neonatal mortality in low-, medium-¹²12. McKinnon B, Harper S, Kaufman JS, Bergevin Y. Socioeconomic inequality in neonatal mortality in countries of low and middle income: a multicountry analysis. Lancet Glob Health 2014; 2(3): e165-73. https://doi.org/10.1016/S2214-109X(14)70008-7
https://doi.org/10.1016/S2214-109X(14)70... and high-income countries¹³13. BilsteenJF, AndresenJB, MortensenLH, Hansen AV, Andersen AMN. Educational disparities in perinatal health in Denmark in the first decade of the 21st century: a register-based cohort study. BMJ Open 2018; 8: e023531. https://doi.org/10.1136/bmjopen-2018-023531
https://doi.org/10.1136/bmjopen-2018-023... . It was able to reveal inequalities in fetal, neonatal and post-neonatal mortality in Denmark, in the first decade of the 21st century¹³13. BilsteenJF, AndresenJB, MortensenLH, Hansen AV, Andersen AMN. Educational disparities in perinatal health in Denmark in the first decade of the 21st century: a register-based cohort study. BMJ Open 2018; 8: e023531. https://doi.org/10.1136/bmjopen-2018-023531
https://doi.org/10.1136/bmjopen-2018-023... . Similar results were described in the birth cohorts of Pelotas (RS), Brazil (1993 to 2004), and Avon, United Kingdom (1991)¹⁴14. Matijasevich A, Victora CG, Lawlor DA, Golding J, Menezes AM, Araújo CL, et al. Association of socioeconomic position with maternal pregnancy and infant health outcomes in birth cohort studies from Brazil and the UK. J Epidemiol Community Health 2012; 66(2): 127-35. https://doi.org/10.1136/jech.2010.108605
https://doi.org/10.1136/jech.2010.108605... . Blencowe et al.⁶6. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health 2016; 4(2): e98-e108. https://doi.org/10.1016/S2214-109X(15)00275-2
https://doi.org/10.1016/S2214-109X(15)00... showed an inverse association between the average years of study and the FMR. The use of maternal education as an indicator of the family's socioeconomic status is recommended in Brazil, for analysis of infant and fetal mortality, by the Ministry of Health¹⁵15. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Manual de Vigilância do Óbito Infantil e Fetal e do Comitê de Prevenção do Óbito Infantil e Fetal. 2ᵃ ed. Brasília: Editora do Ministério da Saúde; 2009.. Studies of temporal trends in infant¹⁶16. Gennuso KP, Kindig DA, Givens ML. Joinpoint Trend Analysis of Infant Mortality Disparities in Wisconsin, 1999-2016. Am J Public Health 2019; 109(5): 714-8. https://doi.org/10.2105/AJPH.2018.304945
https://doi.org/10.2105/AJPH.2018.304945... , neonatal¹⁷17. Fonseca SC, Flores PVG, Camargo Jr. KR, Pinheiro RS, Coeli CM. Maternal education and age: inequalities in neonatal death. Rev Saúde Pública 2017; 51: 94. https://doi.org/10.11606/S1518-8787.2017051007013
https://doi.org/10.11606/S1518-8787.2017... and fetal¹⁸18. Luque-Fernandez MA, Thomas A, Gelaye B, Racape J, Sanchez MJ, Williams MA. Secular trends in stillbirth by maternal socioeconomic status in Spain 2007-15: a population-based study of 4 million births. Eur J Public Health 2019; 29(6): 1043-8. https://doi.org/10.1093/eurpub/ckz086
https://doi.org/10.1093/eurpub/ckz086... mortality have also used maternal education as a socioeconomic indicator. In addition to being corroborated in the literature, it is information present in information systems, allowing population-based analyses.

The present study estimated the trend of FMR and NMR according to avoidable causes of death and maternal education in the city of Rio de Janeiro (RJ), from 2000 to 2018.

METHODS

An ecological study of the historical series of the annual fetal and neonatal mortality rate was conducted, considering the avoidability of the causes of death and maternal education, in RJ from 2000 to 2018.

The sources of mortality and LB data were respectively the Mortality and Live Birth Information Systems of the SUS Department of Informatics. Neonatal deaths and live births were referred to using the data tabulator - Tabnet do Ministério da Saúde ¹⁹19. Brasil. Ministério da Saúde. Portal da Saúde. DATASUS. Informações de Saúde (TABNET). Estatísticas Vitais [Internet]. Brasil: Ministério da Saúde [accessed on Jun. 15, 2020]. Available ate: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6938&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/inf10
http://www2.datasus.gov.br/DATASUS/index... . Fetal deaths were obtained from the databases available for download²⁰20. Brasil. Ministério da Saúde. Portal da Saúde. DATASUS. Serviços. Arquivos de Dados [Internet]. Brasil: Ministério da Saúde [accessed on Jun. 15, 2020]. Available ate: http://www2.datasus.gov.br/DATASUS/index.php?area=0901 and analyzed by the statistical program Stata version 14.0.

Fetal deaths correspond to those with gestational age ≥22 weeks, and neonatal deaths, from 0 to the 27th complete day of life, according to the International Statistical Classification of Diseases and Related Health Problems (ICD), tenth edition²¹21. Organização Mundial da Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde. 10ᵃ rev. São Paulo: CBCD/EDUSP; 1995. 2 v..

Deaths were classified according to the List of Avoidable Causes of Death Due to Interventions of the Brazilian Health System (LBE)²²22. 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(2): 173-6. https://doi.org/10.5123/S1679-49742010000200010
https://doi.org/10.5123/S1679-4974201000... . The classification groups the causes of death into three groups: avoidable deaths; ill-defined deaths; other causes (not clearly avoidable). The group of avoidable causes is composed of six subgroups, considering the type of intervention:

1. 1.1)

   Reducible by immunoprevention;

2. 1.2)

   Reducible by adequate care for woman in pregnancy and childbirth and for fetus and newborn:

   1. 1.2.1)

      Reducible by adequate prenatal care;

   2. 1.2.2)

      Reducible by adequate intrapartum care;

   3. 1.2.3)

      Reducible by adequate care of the fetus and newborn;

3. 1.1)

   Reducible by adequate diagnosis and treatment;

4. 1.2)

   Reducible by health promotion measures linked to adequate healthcare measures.

The LBE was adapted for fetal deaths on the basis of the study of Vieira et al.²³23. Vieira FMDSB, Kale PL, Fonseca SC. Aplicabilidade da Lista Brasileira de Causas de Mortes Evitáveis por intervenção do Sistema Único de Saúde, para análise de óbitos perinatais em municípios dos estados Rio de Janeiro e São Paulo, 2011. Epidemiol Serv Saúde 2020; 29(2): e201942. https://doi.org/10.5123/s1679-49742020000200019
https://doi.org/10.5123/s1679-4974202000... and the proposal of Saúde Brasil 2018¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75.. Vieira et al.²³23. Vieira FMDSB, Kale PL, Fonseca SC. Aplicabilidade da Lista Brasileira de Causas de Mortes Evitáveis por intervenção do Sistema Único de Saúde, para análise de óbitos perinatais em municípios dos estados Rio de Janeiro e São Paulo, 2011. Epidemiol Serv Saúde 2020; 29(2): e201942. https://doi.org/10.5123/s1679-49742020000200019
https://doi.org/10.5123/s1679-4974202000... proposed two changes:

• Allocate fetal deaths whose cause was maternal diabetes (ICD: P70.0 and P70.1) of the subgroup of causes that can be reducible by adequate care of the fetus and newborn to those that can be reducible by adequate prenatal care;

• Consider the code P20.9, which deals with hypoxia without specifying the time of occurrence, ill-defined cause²³23. Vieira FMDSB, Kale PL, Fonseca SC. Aplicabilidade da Lista Brasileira de Causas de Mortes Evitáveis por intervenção do Sistema Único de Saúde, para análise de óbitos perinatais em municípios dos estados Rio de Janeiro e São Paulo, 2011. Epidemiol Serv Saúde 2020; 29(2): e201942. https://doi.org/10.5123/s1679-49742020000200019
  https://doi.org/10.5123/s1679-4974202000... .

The document from the Ministry of Health¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75. argues that some ICD codes applied to fetal deaths generate inconsistency as they are exclusive to newborns, such as P22, P24, P51, P54, P58, P59, P71 to P74 (already mentioned above), P80, P81, P90 to P92 and P94¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Avaliação da qualidade dos dados do óbito fetal no Sistema de Informação sobre Mortalidade do Brasil. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Saúde Brasil 2018: uma análise de situação de saúde e das doenças e agravos crônicos: desafios e perspectivas. Brasília: Ministério da Saúde; 2019. p. 359-75..

We determined the annual fetal deaths per thousand births (the sum of the number of fetal deaths ≥22 weeks of gestation and those with missing information of gestational age divided by the sum of the number of LB, fetal deaths ≥22 weeks and those with missing information of gestational age)¹⁵15. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Manual de Vigilância do Óbito Infantil e Fetal e do Comitê de Prevenção do Óbito Infantil e Fetal. 2ᵃ ed. Brasília: Editora do Ministério da Saúde; 2009. and neonatal deaths per thousand LB¹⁵15. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Manual de Vigilância do Óbito Infantil e Fetal e do Comitê de Prevenção do Óbito Infantil e Fetal. 2ᵃ ed. Brasília: Editora do Ministério da Saúde; 2009. (the sum of the number of neonatal deaths divided by the sum of the number of LB), according to maternal education and the group of LBE and adapted LBE.

Relative annual frequencies of deaths were described according to the avoidability group, and for the subgroup of avoidable causes, the main causes were described (ICD codes).

Using maternal education as a measure of socioeconomic status¹³13. BilsteenJF, AndresenJB, MortensenLH, Hansen AV, Andersen AMN. Educational disparities in perinatal health in Denmark in the first decade of the 21st century: a register-based cohort study. BMJ Open 2018; 8: e023531. https://doi.org/10.1136/bmjopen-2018-023531
https://doi.org/10.1136/bmjopen-2018-023... , specific mortality rates were analyzed, considering low and high education, respectively <4 and ≥12 years of study. Due to the incompleteness of the education variable, 25 and 18%, respectively, for fetal and neonatal deaths, a sensitivity analysis of mortality rates was carried out, allocating all records with missing information for low education and, later, for high education.

For trend analysis, the Joinpoint regression model was used, which fits a series of lines and their joinpoints on a logarithmic scale to demonstrate annual trends. We used the Monte Carlo Permutation Method to test for significance. The direction and magnitude of the estimated trend are represented by the annual percentage variation (APV), with a level of statistical significance of 0.05 being considered. Models with and without autocorrelation term (AC) were evaluated, and the term of AC was maintained in the models in which the APV changed by more than 0.2%. Joinpoint Regression software was used (https://surveillance.cancer.gov/joinpoint//). The trends presented in graphical form were better visualized on the logarithmic scale, allowing to observe the percentage distance between two points.

The present study, addressing RJ, is an integral part of the Study on Health Indicators for Women and Children in the Health Regions of the state of Rio de Janeiro, approved by the Research Ethics Committee of the Faculty of Medicine of Universidade Federal Fluminense (Process No. 4.091.556).

RESULTS

Totals of 15,845 fetal deaths and 14,660 neonatal deaths in RJ were analyzed, of which 23% occurred at term, and for birth weight, 25% of fetuses and 20% of neonates weighed ≥2500 g.

FMR and NMR showed a downward trend from 2000 to 2018: FMR went from 11.1 to 9.3 and NMR from 11.3 to 7.8 (Table 1). Fetal mortality showed an annual reduction of 0.8% for the entire period analyzed, and neonatal mortality showed a joinpoint, indicative of a change in trend in 2007: from 2000 to 2007, the annual decline was more pronounced, approximately 4%, compared to the subsequent period, about 1%, until 2018. Due to the difference in the intensity and duration of the reduction, FMR surpassed NMR as of 2006.

The magnitude and trend of the rates were mainly due to the behavior of deaths classified as avoidable (Table 1). Fetal mortality from avoidable causes showed two joinpoints (2002 and 2011) with a change in the direction of the trend, with only the initial decline (from 2000 to 2002) and the subsequent rise (from 2002 to 2011) being statistically significant. The joinpoint for the total and avoidable NMRs occurred in the same year, 2007.

Fetal and neonatal mortality due to ill-defined causes had respectively three and two joinpoints that did not coincide (Table 1). From 2000 to 2002, there was a significant annual increase in FMRs due to ill-defined causes. Starting in 2002, the first joinpoint in the time series, the trend was decreasing. For neonatal mortality, only in the period from 2013 to 2016 was there a tendency for the annual rate to increase. In the preceding and subsequent periods, there was a decrease. There was a tendency for increased fetal mortality from other causes from 2000 to 2018 and, for neonatal mortality, only from 2000 to 2004.

Among the fetal deaths due to avoidable causes, the predominant subgroups were reducible by adequate prenatal care and reducible by adequate intrapartum care (Table 2). In the first two years, the main subgroup of avoidable causes was reducible by adequate intrapartum care, which moved to second place since then. For neonatal deaths, in all years, the main subgroup was reducible by adequate prenatal care, followed by reducible by adequate care of the fetus and newborn, and reducible by adequate intrapartum care (Table 2).

In the subgroup reducible by adequate prenatal care, the main causes of neonatal death were hypertensive maternal disorders (ICD-P00), followed by respiratory distress in newborns (ICD-P22), from 2000 to 2010, which afterward changed positions in the ranking. For fetal deaths, the two main causes of death were hypertensive diseases and complications of the placenta until 2004. Deaths due to early congenital syphilis have come to occupy the second leading cause of fetal deaths since 2005, except in 2007, when they were overtaken by other and unspecified morphological and functional abnormalities of the placenta (ICD-P02.2) and started to occupy the third position.

The three main causes of fetal deaths in the subgroup reducible by adequate intrapartum care were intrauterine hypoxia before and during labor (ICD-P20.0 and P02.1) and the fetus or newborn affected by umbilical cord compression (ICD- P02.5), and for neonatal deaths (ICD-P02, P21 and neonatal aspiration syndrome - P24) with variations in ranking in the years analyzed.

The codes of the subgroup reducible by adequate care of the fetus and newborn (1.2.3) was second among neonatal deaths, highlighting perinatal infection, for which the newborn's unspecified bacterial sepsis (ICD-P36.9) was mostly the case. For fetal deaths, this subgroup (except for some codes reallocated to the subgroup reducible by adequate prenatal care) was not applied.

Only three cases of pertussis, one of congenital rubella in neonates and two in fetuses made up the immunoprevention group (1.1).

Groups 1.3 and 1.4 of the LBE, related to adequate diagnostic and treatment actions and health promotion measures, respectively, did not apply to fetal deaths. For neonatal deaths, these two subgroups contributed up to about 3% of the total avoidable causes (Table 2).

The fetal and neonatal specific mortality rates according to maternal education are shown in Figure 1. There were higher mortality rates for children of mothers with low education when compared to those of mothers with high education, which is much more pronounced for fetal deaths.

Additionally, the temporal trend was different: fetal mortality for low education had two joinpoints (2005 and 2015), with a significant increasing trend of 13.9% per year between 2005 and 2015. For high education, there was no joinpoint, and no significant trend was detected. Neonatal mortality showed joinpoints and a significant increasing trend for low education (2009 to 2015), with an annual increase of 10.9%. For high education, there was only one joinpoint, with a significant decline in NMR (4.4% per year) between 2000 and 2009, followed by stability (Table 1 and Figure 1). In the sensitivity analysis, the rates only showed a different behavior for high education: for NMR, the declining trend became significant in both periods (APV = −9% up to 2005 and APV = −1.9% in the subsequent period, with AC = −0.4), and for FMR, the trend started to show a decline and significance (APV = −2.8 from 2000 to 2018, with AC = −0.4).

DISCUSSION

We showed a favorable temporal evolution in the reduction of both neonatal and fetal mortality in RJ from 2000 to 2018, albeit slower for FMR. When analyzed according to maternal education, in addition to the inverse relationship with the number of years of study, both fetal and neonatal rates were high and rising among women with low education, revealing inequalities and supporting our study's premise. The sensitivity analysis confirmed the inequalities. Only in the situation where all records with missing information were, in reality, high education, would there be a trend in decline of FMR. However, it seems unlikely, because missing information on maternal education is exactly those related to underprivileged people and distant from health services²⁴24. Mallmann MB, Boing AF, Tomasi YT, Anjos JC, Boing AC. Evolução das desigualdades socioeconômicas na realização de consultas de pré-natal entre parturientes brasileiras: análise do período 2000-2015. Epidemiol Serv Saúde 2018; 27(4): e2018022. https://doi.org/10.5123/s1679-49742018000400014
https://doi.org/10.5123/s1679-4974201800... . As for the upward trend in this range of education, it was confirmed for neonatal death, as had already been described in the state of Rio de Janeiro from 2004 to 2010¹⁷17. Fonseca SC, Flores PVG, Camargo Jr. KR, Pinheiro RS, Coeli CM. Maternal education and age: inequalities in neonatal death. Rev Saúde Pública 2017; 51: 94. https://doi.org/10.11606/S1518-8787.2017051007013
https://doi.org/10.11606/S1518-8787.2017... , and found here even more so for the case of fetal deaths.

Considering studies in middle- and high-income countries, it is concluded that FMR may still undergo further reductions. In 2014, Croatia achieved an FMR of 3.8/thousand births²⁵25. Rodin U, Filipović-Grčić B, Đelmiš J, Glivetić T, Juras J, Mustapić Ž, et al. Perinatal Health Statistics as the Basis for Perinatal Quality Assessment in Croatia. Biomed Res Int 2015; 2015: 537318. https://doi.org/10.1155/2015/537318
https://doi.org/10.1155/2015/537318... , and Argentina 6.6/thousand births²⁶26. Grandi C, Nascente L, Cardoso V. Impacto de la mortalidad fetal sobre la prematurez en Argentina: estudio poblacional. Rev Fac Cien Med Univ Nac Córdoba 2017; 74(4): 386-92. https://doi.org/10.31053/1853.0605.v74.n4.17013
https://doi.org/10.31053/1853.0605.v74.n... . Australia²⁷27. Hilder L, Flenady V, Ellwood D, Donnolley N, Chambers GM. Improving, but could do better: Trends in gestation-specific stillbirth in Australia, 1994-2015. Paediatr Perinat Epidemiol 2018; 32(6): 487-94. https://doi.org/10.1111/ppe.12508
https://doi.org/10.1111/ppe.12508... and the United States²⁸28. Dongarwar D, Aggarwal A, Barning K, Salihu HM. Trends in Stillbirths and Stillbirth Phenotypes in the United States: An Analysis of 131.5 Million Births. Int J MCH AIDS 2020; 9(1): 146-8. https://doi.org/10.21106/ijma.344
https://doi.org/10.21106/ijma.344... , even with a 20-week cut-off point for fetal death, found rates of 7 per thousand in 2015 and 5.7 per thousand in 2017, respectively, both with a decreasing trend. In these last two countries, term fetal mortality accounted for between 8 and 15%²⁷27. Hilder L, Flenady V, Ellwood D, Donnolley N, Chambers GM. Improving, but could do better: Trends in gestation-specific stillbirth in Australia, 1994-2015. Paediatr Perinat Epidemiol 2018; 32(6): 487-94. https://doi.org/10.1111/ppe.12508
https://doi.org/10.1111/ppe.12508... ^,2828. Dongarwar D, Aggarwal A, Barning K, Salihu HM. Trends in Stillbirths and Stillbirth Phenotypes in the United States: An Analysis of 131.5 Million Births. Int J MCH AIDS 2020; 9(1): 146-8. https://doi.org/10.21106/ijma.344
https://doi.org/10.21106/ijma.344... , while in RJ the value exceeded 20%.

As reported for the city and the state of São Paulo²⁹29. Andrews K, Bourroul MLM, Fink G, Grisi S, Scoleze Ferrer AP, Diniz EMA, et al. Time to change focus? Transitioning from higher neonatal to higher stillbirth mortality in São Paulo State, Brazil. PLoS One 2017; 12(12): e0190060. https://doi.org/10.1371/journal.pone.0190060
https://doi.org/10.1371/journal.pone.019... , there was a transition between fetal and neonatal mortality. From 2000 to 2005, NMR was greater than FMR in RJ. However, as of 2006, this relationship was reversed, and FMR remained higher until 2018.

When applying the adapted LBE for fetal deaths, a high percentage stood out in the category of ill-defined, reaching half of the deaths in some years. This is explained by the diagnosis of unspecified intrauterine hypoxia (P20.9), one of the most frequent causes reports in the death certificate of the fetuses. As the investigation of deaths is improved, this percentage tends to decrease³⁰30. Rio de Janeiro. Secretaria Municipal de Saúde do Rio de Janeiro. Subsecretaria de Promoção, Atenção Primária e Vigilância em Saúde. Superintendência de Vigilância em Saúde. Coordenação de Análise da Situação de Saúde. Mortalidade fetal no MRJ [Internet]. Rio de Janeiro: Secretaria Municipal de Saúde do Rio de Janeiro [accesed on Jun. 26, 2020]. Available at: http://www.rio.rj.gov.br/dlstatic/10112/7230662/4299726/MortalidadeFetalnoMRJ_31082020.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... , revealing the real cause and confirming that this is a GC³¹31. Teixeira RA, Naghavi M, Guimarães MDC, Ishitani LH, França EB. Quality of cause-of-death data in Brazil: Garbage codes among registered deaths in 2000 and 2015. Rev Bras Epidemiol 2019; 22(Supl. 3): e19002.supl.3. https://doi.org/10.1590/1980-549720190002.supl.3
https://doi.org/10.1590/1980-54972019000... . Among the avoidable causes, those reducible by adequate prenatal care stood out, especially hypertensive diseases and congenital syphilis, which reinforces the importance of prenatal care, especially for high-risk women⁷7. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths; rates, risk factors, and acceleration towards 2030. Lancet 2016; 387(10018): 587-603. https://doi.org/10.1016/S0140-6736(15)00837-5
https://doi.org/10.1016/S0140-6736(15)00... ^,3232. Hodgins S, Tielsch J, Rankin K, Robinson A, Kearns A, Caglia J. A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations. PLoS One 2016; 11(8): e0160562. https://doi.org/10.1371/journal.pone.0160562
https://doi.org/10.1371/journal.pone.016... ^,3333. Chou VB, Walker N, Kanyangarara M. Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study. PLoS Med 2019; 16(12): e1002990. https://doi.org/10.1371/journal.pmed.1002990
https://doi.org/10.1371/journal.pmed.100... . Studies in RJ in the last decade have shown low percentages of adequate prenatal care and inequalities in access and adequacy³⁴34. Domingues RM, Hartz ZM, Dias MA, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saúde Pública 2012; 28(3): 425-37. https://doi.org/10.1590/s0102-311x2012000300003
https://doi.org/10.1590/s0102-311x201200... ^,3535. Domingues RM, Leal MC, Hartz ZM, Dias MA, Vettore MV. Access to and utilization of prenatal care services in the Unified Health System of the city of Rio de Janeiro, Brazil. Rev Bras Epidemiol 2013; 16(4): 953-65. https://doi.org/10.1590/s1415-790x2013000400015
https://doi.org/10.1590/s1415-790x201300... , in addition to failures in the management of hypertension³⁶36. Vettore MV, Dias M, Domingues RM, Vettore MV, Leal MC. 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(5): 1021-34. https://doi.org/10.1590/s0102-311x2011000500019
https://doi.org/10.1590/s0102-311x201100... . There has also been difficulty in controlling congenital syphilis, evident in high rates of incidence and deaths, and failures in prenatal care are among the main factors for the worsening of the condition in RJ³⁷37. Reis GJ, Barcellos C, Pedroso MM, Xavier DR. Diferenciais intraurbanos da sífilis congênita: análise preditiva por bairros do Município do Rio de Janeiro, Brasil. Cad Saúde Pública 2018; 34(9): e00105517. https://doi.org/10.1590/0102-311X00105517
https://doi.org/10.1590/0102-311X0010551... . Certainly, the inequalities that permeate prenatal care have an impact on the negative outcome of pregnancy. About 80% of fetal deaths occurred in public hospitals in RJ, suggesting the most unfavorable socioeconomic profile of these women³⁰30. Rio de Janeiro. Secretaria Municipal de Saúde do Rio de Janeiro. Subsecretaria de Promoção, Atenção Primária e Vigilância em Saúde. Superintendência de Vigilância em Saúde. Coordenação de Análise da Situação de Saúde. Mortalidade fetal no MRJ [Internet]. Rio de Janeiro: Secretaria Municipal de Saúde do Rio de Janeiro [accesed on Jun. 26, 2020]. Available at: http://www.rio.rj.gov.br/dlstatic/10112/7230662/4299726/MortalidadeFetalnoMRJ_31082020.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... .

As for neonatal mortality, even with a reduction in the period studied, the NMR of 7.8 was higher than that found in other places in Brazil, such as Florianópolis³⁸38. Garcia LP, Fernandes CM, Traebert J. Risk factors for neonatal death in the capital city with the lowest infant mortality rate in Brazil. J Pediatr (Rio J) 2019; 95(2): 194-200. https://doi.org/10.1016/j.jped.2017.12.007
https://doi.org/10.1016/j.jped.2017.12.0... , which reached 5.4 from 2012 to 2014, and Londrina³⁹39. Alves JB, Gabani FL, Ferrari RAP, Tacla MTGM, Linck Júnior A. Sepse neonatal: mortalidade em município do sul do Brasil, 2000 A 2013. Rev Paul Pediatr 2018; 36(2): 132-40. https://doi.org/10.1590/1984-0462/;2018;36;2;00001
https://doi.org/10.1590/1984-0462/;2018;... , 7.5 between 2000 and 2013.

The pattern of avoidability was similar to that of fetal deaths, with a predominance of conditions that could be reduced by adequate care for women in pregnancy. Studies on the effectiveness of prenatal care in reducing neonatal mortality are corroborated³²32. Hodgins S, Tielsch J, Rankin K, Robinson A, Kearns A, Caglia J. A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations. PLoS One 2016; 11(8): e0160562. https://doi.org/10.1371/journal.pone.0160562
https://doi.org/10.1371/journal.pone.016... ^,4040. Wondemagegn AT, Alebel A, Tesema C, Abie W. The effect of antenatal care follow-up on neonatal health outcomes: a systematic review and meta-analysis. Public Health Rev 2018; 39: 33. https://doi.org/10.1186/s40985-018-0110-y
https://doi.org/10.1186/s40985-018-0110-... , and conversely, inadequate prenatal care can increase the risk of neonatal death³³33. Chou VB, Walker N, Kanyangarara M. Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study. PLoS Med 2019; 16(12): e1002990. https://doi.org/10.1371/journal.pmed.1002990
https://doi.org/10.1371/journal.pmed.100... ^,4141. Veloso FCS, Kassar LML, Oliveira MJC, Lima THB, Bueno NB, Gurgel RQ, et al. Analysis of neonatal mortality risk factors in Brazil: a systematic review and meta-analysis of observational studies. J Pediatr (Rio J) 2019; 95(5): 519-30. https://doi.org/10.1016/j.jped.2018.12.014
https://doi.org/10.1016/j.jped.2018.12.0... . The second most frequent group of preventable causes, care for the newborn, was highlighted by unspecified neonatal septicemia. This diagnosis should be considered as a basic cause in neonates, in line with the discussion in older children and adults, in which the GC is considered⁴²42. Santos MRD, Cunha CCD, Ishitani LH, França EB. Mortes por sepse: causas básicas do óbito após investigação em 60 municípios do Brasil em 2017. Rev Bras Epidemiol 2019; 22(Supl. 3): e190012.supl.3. https://doi.org/10.1590/1980-549720190012.supl.3
https://doi.org/10.1590/1980-54972019001... . Approximately 80% of these deaths occurred in preterm neonates and weighing less than 2,000 g (data not shown in the tables). Probably some maternal cause triggered the process of prematurity and low weight, which increases the risk of infection. The diagnosis of sepsis, although clinically relevant³⁹39. Alves JB, Gabani FL, Ferrari RAP, Tacla MTGM, Linck Júnior A. Sepse neonatal: mortalidade em município do sul do Brasil, 2000 A 2013. Rev Paul Pediatr 2018; 36(2): 132-40. https://doi.org/10.1590/1984-0462/;2018;36;2;00001
https://doi.org/10.1590/1984-0462/;2018;... , obscures the investigation of maternal causes and the clarity in the necessary interventions.

As limitations of this work, we point out those inherent to the use of information systems, emphasizing the high percentage of missing sociodemographic information, which makes it difficult to further analyze inequalities. The absence of Death Verification Services in RJ and the flaws in the information in medical records contribute to greater inaccuracy in the certification of causes of death, making it difficult to target preventive measures⁴³43. Kale PL, Mello Jorge MHP, Fonseca SC, Cascão AM, Silva KS, Reis AC, et al. Mortes de mulheres internadas para parto e por aborto e de seus conceptos em maternidades públicas. Ciên Saúde Coletiva 2018; 23(5): 1577-90. https://doi.org/10.1590/1413-81232018235.18162016
https://doi.org/10.1590/1413-81232018235... .

As a strength of the study, the use of population bases and the temporal analysis stand out, which enhanced the understanding of the phenomenon. Although limited by the quality of the data, the databases of the Information Systems on Mortality and Live Births are universal and allow, with low cost and relative speed, the monitoring, and study of small and large population groups. The adaptation of LBE to fetal deaths proved to be adequate and necessary. The use of maternal education indicators as a proxy for inequalities revealed differences in magnitude and trend in mortality. Time trend analyses are crucial to identify patterns and changes in indicators and to associate them with health events or interventions. The choice for the joinpoint model is supported by national and international studies on infant mortality¹⁷17. Fonseca SC, Flores PVG, Camargo Jr. KR, Pinheiro RS, Coeli CM. Maternal education and age: inequalities in neonatal death. Rev Saúde Pública 2017; 51: 94. https://doi.org/10.11606/S1518-8787.2017051007013
https://doi.org/10.11606/S1518-8787.2017... ^,4444. RamalhoAA, Andrade AM, Martins FA, Koifman RJ. Tendência da mortalidade infantil no município de Rio Branco, AC, 1999 a 2015. Rev Saúde Pública 2018; 52: 33. https://doi.org/10.11606/S1518-8787.2018052000280
https://doi.org/10.11606/S1518-8787.2018... ^,4545. Onambele L, Martin-Rodríguez LS, Niu H, Alvarez-Alvarez I, Arnedo-Pena A, Guillen-Grima F, et al. Mortalidad infantil en la Unión Europea: análisis de tendencias en el período 1994-2015. An Pediatr (Barc) 2019; 91(4): 219-27. https://doi.org/10.1016/j.anpedi.2018.10.022
https://doi.org/10.1016/j.anpedi.2018.10... .

Neonatal and fetal deaths decreased in RJ, however insufficiently and still unevenly. In the period from 2010 to 2019, data from the Municipal Health Department⁴⁶46. Rio de Janeiro. Secretaria Municipal de Saúde. Coordenadoria Geral de Articulação Estratégica de Vigilância em Saúde. Coordenação de Análise da Situação de Saúde. Indicadores de Saúde de Residentes no Município do Rio de Janeiro [Internet]. Rio de Janeiro: Secretaria Municipal de Saúde [accessed on Dec. 20, 2020]. Available at: http://www.rio.rj.gov.br/dlstatic/10112/7629558/4299722/IndicadoresNascimentoeMortalidadeMRJ_2010_2020_21_10_20_MRJ.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... showed a reduction in the percentage of adolescent mothers, an increase in prenatal coverage, and stability in the percentage of low birth weight. These indicators are consistent with the reduction of neonatal and fetal mortality in the city.

Observing the transition of FMR and NMR, considering the slower decline in FMR and the high percentages of term fetuses with weight ≥2500 g, it is necessary to direct more efforts to reduce fetal mortality in the city studied. It is necessary to invest in prenatal care and childbirth so that women and their children can have favorable outcomes in this life cycle. As for information and research, it is necessary to improve the quality of the data, to guarantee adequate help in the development of public policies and decision-making.

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