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Hospital Neonatal Mortality in the public network, Rio Grande do Sul,

Brazil, 2010-2014

TYPE OF ARTICLE: ORIGINAL ARTICLE


TITLE: Hospital Neonatal Mortality in the public network, Rio Grande do Sul, Brazil, 2010-2014.

AUTHORS:
Hurtado Castro, Blanca Esmeralda1, Public health specialist
Rosa, Roger dos Santos2, phD in Epidemiology.

AFFILIATIONS:
1

Hurtado Castro, Blanca Esmeralda lato sensu post-graduate student, Federal University of Rio

Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil, esmeralda.hurtado@ufrgs.br


2

Rosa, Roger dos Santos Professor, Federal University of Rio Grande do Sul, Porto Alegre, Rio

Grande do Sul, Brazil, roger.rosa@ufrgs.br

CORRESPONDING AUTHOR DETAILS


Blanca Esmeralda Hurtado Castro
370 Dona Leopoldina St., Apt.302
Lajeado
Rio Grande do Sul
Brazil
95900-000
+55-51-99453250
esmeralda.hurtado@ufrgs.br

Short Running Title: Hospital Neonatal Mortality in the public network, Rio Grande do Sul,
Brazil, 2010-2014.
Guarantor of Submission: The corresponding authors are the guarantors of submission.

TITLE: Hospital Neonatal Mortality in the public network, Rio Grande do Sul, Brazil, 2010-2014.

ABSTRACT

Aims
To describe the hospital neonatal mortality in the public network of Rio Grande do Sul from 2010
to 2014.

Methods
Data were obtained from the Hospital Information Systems of the Unified Health System.

Results
Hospital admissions were concentrated in the early newborn period (84.7%) and male sex
(54.3%). Leading causes of hospitalization were certain conditions originating in the perinatal
period (72.3%), infectious and parasitic diseases (12.7%) and diseases of the respiratory system
(6.3%).
Hospital deaths were mainly in the early newborn period (92%) and male sex (53.2%). Primary
underlying causes of death were disorders originating in the perinatal period (72.6%), congenital
malformations, deformations and chromosomal abnormalities (10.7%) and infectious and
parasitic diseases (5.1%)
The hospital neonatal lethality was 4.1%, higher for woman and in the early newborn period
(4.4%).
50.9% of hospitalizations needed Intensive Care Unit (ICU), predominantly of the early newborn
period (91.3%).
The average length of stay was 11.2 days, higher for woman and in the early newborn period.
About PPP$ 163 million was expended in neonatal hospitalizations, focusing on the early
newborn period (91%) and male sex (53.3%).

Conclusion
Early newborn period registered the higher morbidity and mortality in hospitals, hospitalizations in
ICU, hospitalary case-fatality, days spent in hospital and amount paid to cover the
hospitalizations.

Key words: Infant Mortality, Public Health, Hospital Mortality.

TITLE: Hospital Neonatal Mortality in the public network, Rio Grande do Sul, Brazil, 2010-2014.

INTRODUCTION
The infant mortality rate (IMR) shows the number of children who die before the first day of life. It
is calculated per 1,000 live births in a given year [1], and being considered the classic indicator of
living conditions of this population and to be linked to biological (maternal and child factors),
environmental and assistance factors [2].
The IMR is analyzed according to two periods: (i) neonatal (0 to 27 days of life) and (ii) post
neonatal (20 days to a year old). At the same time, neonatal mortality is divided into early
neonatal period (0 to 6 days of life) and late neonatal period (7 to 27 days of life) [3] (FRANA;
LANSKY, 2009).
The neonatal mortality is one of the most important components in the infant mortality, because of
this period brings for children the greatest risks to become sick and die. Therefore, it is paramount
to offer cares and adequate attentions for increasing the probabilities of survive and have a
healthy life [4] (OMS, 2015).
The neonatal mortality is considered a public health issue and a basic indicator to evaluate the
quality of newborn care in a specific area or service [5] (TENA; AHUED2, 2003 apud DE LA
CRUZ; ROBLES; HERNANDEZ, 2009).
Thus, our aim is to describe the hospital neonatal mortality in the public network from the state of
Rio Grande Sul, a federative unit located in the southern region of Brazil, from 2010 to 2014.

MATERIALS AND METHODS


This was an epidemiological study with population-based, cross-sectional and transversal bases,
based on the public files from the Hospital Information Systems (SIH)/SUS (The Unified Health
System), responsible for the payment of all hospitalizations in the public network of the country.
The SIH/SUS uses as data collection Authorization forms for Hospital Admittance (AIH). The
source data was 1,620 files of type reduced (RD prefix) related to the AIHs from January / 2010

to December / 2014, available on the governmental website www.datasus.saude.gov.br and


corresponding to about 67.6 million hospitalizations.
The cause of hospitalization was reported as the main diagnosis, which motivated the
hospitalization. In the course of this, the diagnosis may have changed, but it was not always
registered on the AIH.
From all neonatal hospitalizations (0 to 27 days of life) of residents of the state of Rio Grande do
Sul, it was selected all of them that finished in death.
To stabilize variations, average annual volume of hospitalizations and neonatal deaths in
hospitals from the period were studied, according to age category at the time of hospitalization (in
days of life).
The economic perspective adopted was the universal public financier (SUS). Thus, the figures
quoted correspond to government spending, not representing "cost" in the technical meaning of
the term. They refer to the amounts paid to public and private providers of hospital services,
according to a table established by the national direction of SUS. The values in Brazilian reais
were converted to the 2012 international dollar average of the period (1 PPP $ = R $ 1.89).
The SIH / SUS data are available on the internet and are in the public domain; therefore, there
was no need to submit the present work to Human Research Ethics Committees.

RESULTS
In the period from 2010 to 2014, there were 77,849 neonatal hospitalizations (0 to 27 days of life)
(112/1000 live births / year) of residents of the state of Rio Grande do Sul in the public health
network, of which 3,155 dead (4.1%; 4,5/1000 live births / year).
Of the neonatal hospitalizations, 36,219 (46.5%; 122/1000 live births / year) were residents of the
Metropolitan Region of Porto Alegre. Highlighting the largest amount was the state capital, the
municipality of Porto Alegre (14,016; 18%; 87.3/1000 live births / year). Similarly, among neonatal
deaths occurred in hospitals, 1,262 (40%, 4.3 / 1000 live births / year) belonged to the same

metropolitan region, with special mention to deaths in the capital (440; 13.9%; 2.7/1000 live births
/ year).
65,924 (84.7%) neonatal admissions were early (0 to 6 days), with 36,825 (47.3%)
hospitalizations on the first day of life and 42,279 (54.3%) hospitalizations in the male sex. With
regard to neonatal deaths in hospitals, 2,903 (92%) occurred in the early neonatal period, of
which 2,479 (78.6%) were on the first day of life and 1,679 (53.2%) in men (Table 1).
According to the diagnostic categories of the International Classification of Diseases - 10th
Revision (ICD-10), neonatal hospitalizations were mainly caused by certain conditions originating
in the perinatal period (72.3%), infectious and parasitic diseases (12.7%), diseases of the
respiratory system (6.3%), congenital malformations, deformations and chromosomal
abnormalities (2.8%) and diseases of the digestive system (1.6%) (Table 2).
The ICD-10 categories that led to more neonatal deaths were certain conditions originating in the
perinatal period (72.6%), congenital malformations, deformations and chromosomal abnormalities
(10.7%), infectious and parasitic diseases (5.1%), diseases of the digestive system (3.9%) and of
the respiratory system (3.5%) (Table 3).
The conditions originating in the perinatal period, of the biggest group, represented 37.4% of
hospitalizations on the first day of life and 66.3% in the first week of life. Infectious and parasitic
diseases reached 5.8% of hospitalizations in the first 24 hours of life and 10.8% in the early
neonatal period. As for the deaths, the conditions originating in the perinatal period also
corresponded to 64.1% on the first day of life and 71.6% in the first week of life. Congenital
malformations, deformations and chromosomal abnormalities represented 5.9% of deaths in the
first 24 hours of life and 8.3% in the early neonatal period.
The neonatal lethality in hospitals was 4.1%, higher in female neonates (4.1%) than in male
(4.0%) ones and in the early neonatal period (4.4%), especially on the first day of life (6.7%).
The use of the Intensive Care Unit (ICU) was necessary for 39,461 (50.9%) hospitalizations with
21,674 hospitalizations in the male sex (p <0.05). The distribution by age component in the ICU
was predominant for infants in the early neonatal period (36,191; 91.3%), standing out newborns

on the first day of life (26,210; 66.1%). This specialized unit was used by 54.9% of
hospitalizations in the early neonatal period and 71.2% of patients with less than 24 hours of life.
By contrast, only 28.9% of admissions during the late neonatal period used the ICU.
The ICD-10 categories that demanded greater use of the ICU were certain conditions originating
in the perinatal period (75.4%), infectious and parasitic diseases (11.8%), congenital
malformations, deformations and chromosomal abnormalities (4.3%), diseases of the respiratory
system (3.2%) and of the digestive system (2.1%).
Of the 2,863 neonatal deaths in the ICU, 1,500 were of males (p <0.05). Of the deaths, 2,638
corresponded to the early neonatal component and 225 to the late neonatal component,
emphasizing the large number of infants with less than 24 hours of life (2,259). The main causes
of death in the ICU were certain conditions originating in the perinatal period (73.3%), congenital
malformations, deformations and chromosomal abnormalities (10.4%) and infectious and
parasitic diseases (5.2%).
The average number of days of hospitalization was 11.2 days, it was higher in woman (11.5 days)
than in men (11.0) and in the early newborn period (11.9 days) compared to the late neonatal
period (7.7 days), more specifically in neonates hospitalized on the first day of life (15.6 days).
In the period from 2010 to 2014, expenditures with neonatal hospitalizations amounted to PPP$
163 million. The spending was concentrated in the early neonatal component (91%), explicitly in
the hospitalizations on the first day of life (71.5%) and in the male sex (53.3%).
Neonatal hospitalization expenditure averaged in parity purchase power (PPP) was PPP$
2,093.58. It was higher in the early neonatal component (PPP$ 2,249.51), in hospitalizations in
the first 24 hours of life (PPP$ 3,165.89) and in women (PPP$ 2,139.46). The public network
spent an average of PPP$ 186.32 per day of hospitalization. Spending was higher in the early
neonatal period (PPP$ 189.34), especially in newborn infants on the first day of life (PPP$
292.85) and in the male sex (PPP$ 186.92).

DISCUSSION
Rio Grande do Sul had 6% of neonatal hospital admissions in the country during the period, but
only 4.6% of deaths [6]. Most of the hospitalizations occurred in the early neonatal component
(65,924; 84.7%), especially in children less than 24 hours of life (36,825; 47.3%), and in men
(42,279; 54.3% ).
Ferrer (2009) analyzed the hospitalizations of children in the SUS, children from 0 to 9 years old,
in the municipality of So Paulo. Of the more than 450,000 hospitalizations, hospitalizations of
children under one year of age (74%) were higher than those of children aged 1-4 years (16%) or
those under 5 years old (10%). The hospitalizations of male children (56%) also predominated [7].
Likewise, the number of neonatal hospitalizations in Rio Grande do Sul over the period was
higher when there was proximity to the date of birth and in men.
Most of deaths occurred in the early neonatal period (2,903; 92%), basically in newborns on the
first day of life (2,479; 78.6%) and male sex (1,679; 53.2%).
Bando et al. (2014) pointed out that 72.7% of registered neonatal deaths occurred in the first
week of life [2]. A similar result was found by Nascimento et al. (2012) in which 79.5% of neonatal
deaths occurred in the early neonatal period, specifically 31% in the first 24 hours of life and
58.3% in male [8].
For Araujo, Bozetti and Tanaka (2000), the frequency of deaths on the first day of life
(approximately 50% of cases) shown in the early neonatal component decreases progressively in
the days after. Also, the cases that evolved to death were mostly men (64.3%) [9].
Although the proportions are not exactly the same, they are close to those of the present study. It
is observed that the frequency of death is related to the proximity to the date of birth, as well as to
the male sex of the newborn.
The neonatal hospitalizations were mainly caused by certain conditions originating in the perinatal
period (72.3%), infectious and parasitic diseases (12.7%), diseases of the respiratory system
(6.3%), congenital malformations, deformations and chromosomal abnormalities (2.8%) and
diseases of the digestive system (1.6%). Oliveira, Costa and Mathias (2012) reported similar

causes of hospitalizations in children, such as respiratory diseases (54.6%), infectious and


parasitic diseases (1.5%) and perinatal diseases (12.6%) [ 10]. Ferrer (2009) also identified the
trend of hospitalizations due to diseases of the respiratory system (38.4%), infectious and
parasitic diseases (21.7%), diseases originating in the perinatal period (10.1%) and diseases of
the digestive system (6.4%) [7]. These results reinforce the previous findings about the most
frequent causes of neonatal morbidity and in the specific requests for hospital care in public
health services.
The main causal categories of neonatal death were certain conditions originating in the perinatal
period (72.6%), congenital malformations, deformations and chromosomal abnormalities (10.7%),
infectious and parasitic diseases (5.1%), diseases of the digestive system (3.9%) and of the
respiratory system (3.5%). Gorgot et al. (2011) showed that infant deaths were mainly caused by
disorders of newborn related to short pregnancy and low birth weight (47.6%), acute bronchiolitis
(6.1%), neonatal aspiration syndrome (4.9%), sudden infant death syndrome (4.9%), bacterial
pneumonia (3.7%), congenital syphilis (2.4%) and congenital hydrocephalus (2.4%). According to
this study, 71.2% of neonatal deaths occurred in the early neonatal period. It was also pointed
that more than half of all neonatal deaths would be preventable through adequate care for women
- during pregnancy and childbirth - (48.8%), newborns (3.7%) and adequate diagnostic, treatment
and health promotion (2.4%) [11].
Conditions originating in the perinatal period are relevant, because they constitute 37.4% of
admissions on the first day of life and 66.3% in the first week of life. Infectious and parasitic
diseases are also noteworthy, for corresponding 5.8% of hospitalizations in the first 24 hours of
life and 10.8% in the early neonatal component.
In relation to deaths, conditions originating in the perinatal period show their value, since they
represent 64.1% of all deaths on the first day of life and 71.6% in the first week of life. Similarly,
congenital malformations, deformities and chromosomal abnormalities are important by
representing 5.9% of deaths in the first 24 hours of life and 8.3% in the early neonatal component.
It is observed that high rates of hospitalizations and neonatal deaths in hospitals happen in

periods of early age and are related, most of them, to diseases sensitive to primary health care
level, for example certain conditions originating in the period perinatal. This fact could be
associated to deficiencies in coverages, as well as to the low resolution in the care of women
during pregnancy and delivery, and of the newborn children, in the public health services,
meaning the inefficiency of health care.
Nascimento et al. (2012) indicate that neonatal mortality in the early period suggests causes of
death associated mostly with precarious care of mothers during prenatal and delivery, and
inadequate care for children in delivery rooms and neonatal units [12].
The epidemiological profile of neonatal morbidity and mortality in the present study aims to
change the situation, which depends on the development of specific strategies and actions in the
perinatal period, as well as maternal and child services.
It was evidenced that approximately one in twenty-five newborns in public hospitals from Rio
Grande do Sul ended in death. The lethality increased according to the female sex and the
proximity with the date of birth.
In relation to the use of hospital beds in the neonatal ICU, it was observed that one in two
neonates needed the specialized unit (50.9%). The use of the ICU by half of the newborn
population implies a noticeable rise in expenditures, due to the use of equipment with greater
complexity and specialized and trained professionals.
Furthermore, it was noted that the percentage of newborns hospitalizations in the ICU was higher
for males (54.7%). The finding from this review is similar to the previous report of Tadielo et al.
(2013), for whom 57% of hospitalized neonates in the ICU were men [13]. In the same way, Arru
et al. (2004) demonstrated the predominance of male hospitalizations in an ICU (58%). Thereby,
the superior tendency of use of the ICU was for the male sex [14].
It was also noted in the ICU that there was an increased use by the population at an earlier age,
principally by infants on the first day of life. The hospital neonatal admissions were at an earlier
age, and there was greater use of the specialized unit.

The ICD-10 categories that had most use of the ICU were certain conditions originating in the
perinatal period (75.4%), infectious and parasitic diseases (11.8%), congenital malformations,
deformations and chromosomal abnormalities (4.3%), diseases of the respiratory system (3.2%)
and of the digestive system (2.1%).
These results agree with Granzotto et al. (2012). The ICU was represented mainly of preterm
infants (about 70%), low birth weight, cases with birth asphyxia, 40% of patients with mechanical
ventilation, mothers with high exposure to infection, use of antibiotics in almost 80% of newborns,
and 70% of cesarean births [15].
In the same way, for Arru et al. (2004), the main reasons for neonatal hospitalization in a public
ICU were prematurity and respiratory distress, hematological disorders and infection [14]. Tadielo
et al. (2013) also refer as the main factors for neonatal hospitalization in an ICU: prematurity,
respiratory failure and infections [13].
The research demonstrates demand for hospital beds in the specialized unit, especially for the
population in the early component, as well as the most frequent causes for their use. This
indicates that the dimensioning of neonatal Intensive Care Units must be in accordance with the
specific health demands of neonates at risk, in order to guarantee the solution of needs.
The proportion of use of ICU for all neonatal hospital deaths was high (90.7%). There was a
higher proportion use (92.3%) for the female population who died and for the early neonatal
component (90.9%), especially in children on the first day of life (91.1%). In the present study, the
high percentages of hospitalizations and deaths in ICU represent a warning to analyze these
specialized services and the reality involved in the search for explanations that support their
occurrence.
The number of days that a neonate remains in a public hospital was higher for younger ones. This
result coincides with the study by Ferrer (2009) in which the mean number of days of childrens
hospitalization fell in relation to the progressive age [7].

For Mwamakamba and Zucchi (2014), in the preterm infants admitted in the public hospital, the
average stay in hospitals and the average stay in the ICU increased in relation to low birth weight
[16]. However, data of the AIH system do not contemplate the last variable.

Although studies are heterogeneous, they make it possible to outline that the average of
hospitalization days depends on the proximity to the date of birth, the causes of hospitalization
and the sex of the child.
It is necessary to contextualize that the longer a child is hospitalized, the greater the cost of
hospitalization, in addition to the significant cost of admissions in the ICU.
In the study period, expenditures with neonatal hospitalizations were high (close to PPP$ 163
million). The expenditure was mainly with the population of less than one week of life (91%) and
male (53.3%). The average spending was higher in the hospitalized patients at an earlier stage,
being higher for the hospitalized children on the first day of life (PPP$ 202.85). The results are
close to Mwamakamba and Zucchis study (2014), for whom the average daily expenses of
hospital admissions of preterm infants ranged from PPP$ 115,66 to PPP$ 187,20 [16].
Some limitations of the study have to be highlighted. As the source were secondary data from the
Hospital Information Systems of the Unified Health System (SIH/SUS), there may be some
deficiencies in the quality and accuracy of these, which may also have affected the results taking
in account that it was an analysis of the available variables.
Another point to be considered is that the data relate to the incidence of death occurring within
public hospitals, meaning that deaths after the discharge date or in hospitals not linked to the
public network were not counted, because of they do not fall in the calculation of death
occurrences of the SIH / SUS.

CONCLUSION
The early neonatal component, especially the first day of life, concentrates the largest number of
cases of morbidity and mortality, use of specialized beds, deaths in the ICU, mortality, as well as

the maximum hospital stay and the highest value paid for neonatal admissions. This is one of the
main concerns for children's health; therefore, it must be approached in a strategic way.
One implication that emerges from the study is that the public resources have been expended
with hospitalizations that many times could have been avoided with an adequate health care with
pregnant and newborns.
Efforts to control the birth of children with conditions originating in the perinatal period should be
directed because they represent about 72% of morbidity and mortality cases. Also, evaluating
public hospitals capacity for resolution, that should have appropriate obstetrical and neonatal
services, as well as neonatal intensive care units with supplies, technologies and competent
professionals who were able to offer skilled care.

CONFLICT OF INTERESTS
There is no conflict of interest.

CONTRIBUTIONS OF THE AUTHORS


Roger dos Santos Rosa
Group 1 - Conception and design, data acquisition, analysis and interpretation of data.
Group 2 Elaboration of the article, critical review of the article.
Group 3 Final approval of the version to be published.

Blanca Esmeralda Hurtado Castro


Group 1 - Conception and design, data acquisition, analysis and interpretation of data.
Group 2 Elaboration of the article, critical review of the article.
Group 3 Final approval of the version to be published.

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in

TABLES
Table 1: Hospitalizations and neonatal deaths in the public network in RS, according to age group and sex, 2010-2014.
Hospitalizations
Neonatal
Component

Female
n

Early neonatal
0 day
1 day
2 a 6 days
Late neonatal
Total

30.249
16.860
4.358
9.031
5.321
35.570

Deaths

Male
%

85,0
47,4
12,3
25,4
15,0
100,0

Total
%

35.675
19.965
5.257
10.453
6.604
42.279

Female

84,4
47,2
12,4
24,7
15,6
100,0

65.924
36.825
9.615
19.484
11.925
77.849

84,7
47,3
12,4
25,0
15,3
100,0

Male

1.363
1.181
109
73
113
1.476

92,3
80,0
7,4
4,9
7,7
100,0

Total
%

1.540
1.298
160
82
139
1.679

91,7
77,3
9,5
4,9
8,3
100,0

2.903
2.479
269
155
252
3.155

92,0
78,6
8,5
4,9
8,0
100,0

Table 2: Neonatal hospitalizations in the public network by age group and main diagnostic group ICD-10, Rio Grande do Sul,2010-2014
Hospitalizations
Early neonatal
Groups ICD-10
Certain conditions originating in the
perinatal period.

0 Day 1 Day

Late neonatal

General

2a6
Days

Total

Total

Total

29.078

7.016

15.512

51.606

78,3

4.657

39,1

56.263

72,3

Infectious and parasitic diseases.

4.506

1.757

2.151

8.414

12,8

1.479

12,4

9.893

12,7

Diseases of the respiratory system.

1.009

300

404

1.713

2,6

3.175

26,6

4.888

6,3

Congenital malformations, deformations


and chromosomal abnormalities.

941

236

416

1.593

2,4

563

4,7

2.156

2,8

Diseases of the digestive system.

390

89

198

677

1,0

568

4,8

1.245

1,6

Others

901

217

803

1.921

2,9

1.483

12,4

3.404

4,4

36.825

9.615

19.484

65.924 100,0

11.925

100,0

77.849

100,0

Total general

Table 3: Neonatal deaths in the public network by age group and main diagnosis group ICD-10, Rio Grande do Sul, 2010-2014.
bitos
Groups ICD-10
Certain conditions originating in the
perinatal period.
Infectious and parasitic diseases.
Diseases of the respiratory system.
Congenital malformations, deformations
and chromosomal abnormalities
Diseases of the digestive system
Others
Total general

0 Day

Early neonatal
1 2a6
Total
Day Days

Late neonatal

General

Total

Total

2.022

192

46

2.260

77,9

32

12,7

2.292

72,6

90

18

16

124

4,3

38

15,1

162

5,1

57

13

79

2,7

30

11,9

109

3,5

185

26

50

261

9,0

78

31,0

339

10,7

50

18

75

2,6

49

19,4

124

3,9

75

13

16

104

3,6

25

9,9

129

4,1

2.479

269

155

2.903

100,0

252

100,0

3.155

100,0