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ORIGINAL ARTICLE
Neonatal mortality at Hospital Geral do Grajaú
Mortalidade neonatal no Hospital Geral do Grajaú*
José Ricardo Dias Bertagnon1, Jane de Eston Armond2, Magda Santos Torres3, Josiane Carignani4
ABSTRACT
RESUMO
OBJECTIVES: To analyze the characteristics of neonatal deaths at
Hospital Geral Grajaú, in 2002, and assess the influence of perinatal
factors in mortality. METHODS: A retrospective and descriptive
study, including all births that took place at Hospital Geral do Grajaú,
in the city of São Paulo, in 2002, totaling 2,694 newborns. The
causes of death were classified as “maternal-related”, “fetusrelated”, “delivery-related”, “newborn-related”, and “institutional”
causes. They were also classified as avoidable and unavoidable
regarding institutional resources. The chi-square test (p < 0.05)
was applied to study anoxia and mortality data. RESULTS: The
percentage of death among all liveborn neonates was 1.19%; in
that, 52% with extremely low birth weight, 34.48% with very low
birth weight, and 7.22% with low birth weight babies. The
extremely-low-birth-weight neonates (weight < 1,000 g)
represented 0.93% of the live-borns and 40.62% of the deaths.
The very-low-birth-weight babies (weight < 1,500 g) accounted
for 2.16% of the population studied and 62.49% of the deaths;
whereas the low-birth-weight neonates (weight < 2,500 g)
represented 13.36% of the live-borns and 81.23% of the deaths.
Mortality by specific weight decreased in all groups except for the
2,500-4,000 g group, which presented a rate higher than the
previous groups (in absolute numbers) for comprising more
neonates. Most deaths occurred in the first 7 days of life, and
25%, after 28 days. Neonatal mortality rate was 8.91%0. Early
neonatal mortality rate was 6.31% 0 and late hospital neonatal
mortality rate was 2.60%0. Intrauterine infection, malformation, and
severe anoxia accounted for 56.27% of the causes of death. It was
possible to identify the non-hospital related causes (external
factors) in 75% of the cases. Anoxia was significantly associated
to mortality. CONCLUSIONS: Neonatal mortality at Hospital Geral
do Grajaú was comparable to that observed in the State of São
Paulo. Perinatal anoxia was significantly associated to neonatal
mortality. Unavoidable causes accounted for 64% of deaths.
OBJETIVO: Conhecer características dos neomortos no Hospital Geral
do Grajaú, no ano de 2002 e avaliar a influência de fatores perinatais
na mortalidade. MÉTODOS: Estudo retrospectivo, descritivo, incluindo
todos os nascimentos no ano de 2002 no Hospital Geral do Grajaú,
São Paulo, num total de 2.694 recém-nascidos. Os óbitos classificaramse como de “causas maternas”, de “causas fetais”, “causas relativas
ao parto”, ao “recém-nascido” e “casos institucionais”, sendo
“evitáveis” e “inevitáveis” diante dos recursos institucionais. Foi feito
o teste do qui quadrado (p < 0,05) para análise dos dados referentes
à anóxia e mortalidade. RESULTADOS: A porcentagem dos óbitos foi
de 1,19% de todos os nativivos; entre os de extremo baixo peso foi de
52%; entre os de muito baixo peso foi de 34,48% e entre os de baixo
peso foi de 7,22%. Os nascidos de extremo baixo peso (todos com
peso < 1.000 g), representando 0,93% dos nativivos, foram
responsáveis por 40,62% dos óbitos. Os de muito baixo peso (todos
com peso < 1.500 g) ou 2,16% da população, representaram 62,49%
da mortalidade e os nascidos de baixo peso (todos com peso < 2.500
g) ou 13,36% dos nativivos, foram responsáveis por 81,23% dos óbitos.
A mortalidade por grupo específico de peso caiu até o grupo de 2.500
a 4.000 g onde, por agrupar categoria maior, foi maior em números
absolutos do que na categoria anterior. A maior parte dos óbitos
ocorreu com menos do que 7 dias e 25% deles com mais de 28 dias.
O coeficiente de mortalidade neonatal foi de 8,91%0. O coeficiente de
mortalidade neonatal precoce foi de 6,31% 0 e o coeficiente de
mortalidade neonatal tardio hospitalar foi de 2,60%. Infecção intrauterina, malformações e anóxia grave representaram 56,27% das
causas de óbito e em 75% dos casos foi possível identificar causas
relacionadas a fatores externos ao hospital. Anóxia mostrou-se
significativamente associada à mortalidade. CONCLUSÃO: A
mortalidade neonatal no Hospital Geral do Grajaú foi comparável à do
Estado de São Paulo. Anóxia perinatal foi significativamente associada
a mortalidade neonatal. Causas inevitáveis foram responsáveis por
64% dos óbitos.
Keywords: Infant mortality; Infant, newborn; Hospital, general;
Mortality
Descritores: Mortalidade infantil; Recém-nascido; Hospitais gerais;
Mortalidade
* Study at Hospital Geral do Grajaú - Teaching hospital of the University of Santo Amaro.
1
Ph.D. in Perinatal Medicine, Healthcare Institute of Civil Servants of the State of São Paulo. Attending Physician at Neonatal Unity, Hospital Geral do Grajaú.
Professor of Epidemiology at Santo Amaro University. Director of the Health District of Capela do Socorro.
Master’s Degree in Pediatrics, Santa Casa Medical School. Attending Physician at Neonatal Unity, Hospital Geral do Grajaú.
4
Master’s Degree in Pediatrics, University of São Paulo. Attending Physician at Neonatal Unity, Hospital Geral do Grajaú.
2
3
Correspondence to: José Ricardo Dias Bertagnon - R. Francisco Romeiro Sobrinho, 171 - CEP 0410-180 - São Paulo - SP.
Recebido para publicação em 2/6/2003 – Aceito em 20/8/2003
einstein 2003; 1:9-13
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Bertagnon JRD, Armond JE, Torres MS, Carignani J
INTRODUCTION
Neonatal mortality is the type of mortality (among infants) less
affected by variations resulting from social and educational actions(1).
Infant mortality decreased in Brazil in the last few years probably
because of the public health education programs such as immunization,
oral rehydration therapy, and breastfeeding incentive(2).
Neonatal mortality picture can be changed by technological
developments and training of skilled professionals for prenatal
actions, delivery care, and breastfeeding(1).
As new technological and specialized advances are
employed, there is an increase in newborn survival and a shift
in mortality from early to late neonatal period, mainly among
the very low birth weight (VLBW), that is, newborns weighing
less than 1,500g(1-3).
Hospital Geral do Grajaú (HGG) serves a population segment
living on the outskirts of the city of São Paulo, characterized by the
high prevalence of adolescent mothers, high rate of low birth weight
newborns (LBWN) (< 2,500g), and low rates of prenatal care.
Perinatal hypoxia and high mortality rate are associated to these
characteristics(1,3).
Studying the progress of a newborn in the neonatal unity giving the due value to prenatal care, socioeconomic conditions,
and maternal health, obstetric and delivery complications - could
help to diagnose the causes related to poor obstetric results and
neonatal and fetal morbidity and mortality(1,3-5).
Causes of poor obstetric results may be related to macroenvironment(6), maternal-related environment and microenvironment(7) according environmental influences, maternal disease
status, or etiology related to placental or fetal problems
respectively(8).
OBJECTIVES
All newborn deaths (n = 32) were studied for maternal and
obstetric factors, diagnosis of newborn conditions, length of stay
in neonatal unit, and causes of death through analysis of newborn
and mother’s medical charts, and death certificate.
Conditions related to death were classified based on etiology
and pathogenesis and as the following types of causes: fetal,
maternal, delivery-related, prematurity, and institutional flaws,
according to the criteria mentioned by Noronha et al.(10).
Neonatal death of infants who were born with evidence of
infectious process, related to prematurity or severe anoxia, and of
those who arrived at hospital during the second stage (expulsion)
were classified as “maternal causes”. Deaths of malformed
newborns who died due to the malformation were classified as
“fetal causes”. Deaths of newborns with evidence of severe anoxia
with no signs of intrauterine infection or malformation, and birth
weight > 2,000 g, were classified as “delivery-related causes”.
“Prematurity causes” were related to deaths of newborns with birth
weight < 750 g, pulmonary immaturity and no evidence of
infection. Deaths of newborns due to nosocomial infection were
classified as “institutional causes”.
The causes of death were also classified as avoidable and
unavoidable according to institutional resources, and based on
assessments by the Perinatal Mortality Analysis Committee of
HGG. The following causes were considered unavoidable:
malformation incompatible with life, neonates with birth weight
< 750 g and born with evidence of infection and/or severe anoxia,
and whose mother arrived at hospital during the second stage of
delivery (expulsion).
Chi-square test was used to examine data regarding anoxia and
perinatal mortality.
RESUL TS
To analyze some characteristics of neonatal mortality at Hospital
Geral do Grajaú in 2002 and to assess the influence of perinatal
factors on mortality.
The following birth weight distribution was gathered: low birth
weight (LBW): 13.36%; very low birth weight (VLBW): 2.16%;
extremely low birth weight (ELBW) (weight < 1,000 g): 0.93%.
Table 1 shows the distribution of newborns according to weight
and mortality.
METHODS
Table 1. Newborns per birth weight and mortality
This is a retrospective, descriptive study. A case-control study was
conducted to assess the influence of neonatal anoxia.
The study was performed at HGG, in the southern region of
the city of São Paulo. It is the teaching hospital of the University
of Santo Amaro Medical School, and a reference hospital for
high-risk pregnancy. It serves the population from the health
districts of Grajaú, Socorro, Cidade Dutra, Parelheiros, and
Marsilac. This population is characterized by high infant and
neonatal mortality rates, in addition to high rate of low birth
weight newborns(9).
The sample comprised all liveborn newborns at HGG, in 2002,
totaling 2,694 newborns.
Data regarding birth weight and Apgar score were
collected from the hospital’s delivery room recording book.
Delivery-related data are recorded in this book and later
copied to the medical chart of the patient; therefore no record
fails to be made.
einstein 2003; 1:9-13
Weight
(g)
Liveborn
(n)
Death
(n)
Weight-specific
mortality (%)
Mortality
RF (%)
Mortality
CF (%)
500-749
750-999
1000-1249
1250-1499
1500-1749
1750-1999
2000-2249
2250-2499
2500-3999
> 4000
Total
10
15
15
18
40
49
65
148
2260
74
2694
9
4
4
3
1
1
0
4
6
0
32
90.0
26.7
26.7
16.7
2.5
2.04
0.00
2.70
0.26
0.00
1,19
28.12
12.5
12.5
9.37
3.12
3.12
0.00
12.5
18.75
0.00
100
0.0
40.62
53.12
62.49
65.61
68.73
68.73
81.23
99.98
99.98
100
Mortality RF = Mortality Relative Frequency
Mortality CF = Mortality Cumulative Frequency
The percentage of deaths was 1.19% for all liveborn neonates.
Neonatal mortality at Grajaú General Hospital
Table 2 shows the length of survival of newborns during the
neonatal period.
Table 2. Neonatal deaths per length of survival
Length of survival (days)
(n)
RF (%)
<7
17
53.20
7 - 28
7
21.90
> 28
8
25.00
Total
32
100.0
RF = Relative Frequency
11
Table 6. Neonatal death per cause of death
Cause of death Number
RF (%)
Intrauterine infection
7
21.86
Nosocomial infection
7
21.86
Malformation
Severe neonatal anoxia
6
5
18.75
15.66
Pulmonary immaturity
4
12.50
Narcotizing enterocolitis
2
6.25
Acute renal failure
1
3.12
Total
32
100.00
RF = Relative Frequency
Most deaths occurred in the first 7 days of life, and 25% after
28 days; therefore not within the neonatal period.
Neonatal mortality rate was 8.91%0. Early neonatal mortality
rate was 6.31%0, and late hospital neonatal mortality rate was 2.60%0.
Frequency of deaths during the neonatal period according to
number of prenatal consultations and gestational age are shown
on tables 3 and 4, respectively.
Table 3. Frequency of neonatal deaths per number of prenatal consultations
Number of prenatal consultations
(n)
RF (%)
0
1- 2
3-4
>5
Total
17
5
5
5
32
53.14
15.62
15.62
15.62
100.00
Table 7 shows the classification used for causes of death.
Table 7. Classification used for causes of neonatal death
Cause of death
Number
RF (%)
Institutional
8
25.00
Maternal
7
21.86
Delivery-related
7
21.86
Fetal
6
18.75
Prematurity
4
12.50
Total
32
100.00
RF = Relative Frequency
It was possible to identify the non-hospital-related causes
(external causes) of death in 75% of the cases. It was also observed
that the cause of death was unavoidable in 68.75% of the cases.
RF = Relative Frequency
Table 4. Frequency of neonatal deaths per estimated gestational age
DISCUSSION
Gestational Age (weeks)
(n)
RF (%)
<28
12
34.34
28 - 34
35 - 36
10
3
31.34
9.41
> 37
Total
7
32
21.81
100.00
Knowledge of factors affecting poor obstetric results enables
establishing preventive measures(8,10). The decrease in neonatal
mortality rates depends on multifactorial causes such as socioeconomic factors, prenatal access, quality of prenatal care, maternal
morbidity, difficulty in screening malformations, assistance to
newborns in delivery room, access to technology specifically
adequate to treatment newborns, among others(11). The evaluation
of prenatal care services, delivery and newborn care, in addition to
knowledge of the population assisted comprise the indispensable
tools to change neonatal morbidity and mortality rates(8,10-13).
Birth weight may be the most commonly used indicator to study
mortality risk. The distribution of LBW, VLBW and ELBW shows
the level of complexity, and contribute for the mortality rate at
HGG. However, it is known that the higher these rates, the worse
the health conditions of the population and their socioeconomic
situation(8-9,11-15).
In the United States, the rate of VLBW is approximately 1.4%
among all liveborn infants, and it has remained constant for ten
years (8) . In maternity hospitals in São Paulo, this rate was
approximately 2.1%, in 1992(9). At Albert Einstein Jewish Hospital
(HIAE), serving a high-income population in the city of São Paulo,
the rate for VLBW infants was 1.31%, in 2000(15). At the maternity
hospital of Vila Nova Cachoeirinha (MEVCN), in the city of São
Paulo, this rate was 3.82%, in 1990(12). The rate of VLBW found
for the population studied was within these limits.
RF = Relative Frequency
Table 5 shows the frequency of newborns who survived and of
those who died in the neonatal period per Apgar score.
Table 5. Frequency of survival and death per 1-minute apgar score
Apgar
Survival Death Total
8, 9 or 10
7
4, 5 or 6
0, 1, 2 or 3
2243
195
168
56
3
2
11
16
2246
197
179
72
Total
2662
32
2694
c2 = 330.21; p < 0.000...; Apgar RR >7 x Apgar <4 = 1.28.
There is a significant association (p < 0.05) between the variables and relative risk of death
for newborns with Apgar score < 4. The risk for this group was 1.28-fold higher than for
newborns whose Apgar score was > 7.
Table 6 shows the causes of neonatal deaths.
einstein 2003; 1:9-13
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Bertagnon JRD, Armond JE, Torres MS, Carignani J
In 2001, LBW rate was 9.3% at the district of Grajaú; in 2002,
at HGG the rate was 13.4% indicating that HGG is a reference
hospital for highrisk pregnancy(9).
Survival rate of VLBW neonates varies from service to service.
Hack(16) carried out a study in the United States, in 1995, and
demonstrated the following survival rates: 39% for newborns
weighting 500-749 g; 77% for 750-999 g; 90% for 1,000-1,249 g;
and 93% for 1,250-1,499 g; therefore higher than the rates found
in this study. The influence of socioeconomic factors on health is
well known (1-6). Neonatal anoxia is an aggravating factor for
neonatal mortality, especially in VLBW newborns(1-3,13-15). This fact,
associated with the low use of prenatal care services, may increase
mortality rates, primarily in the VLBW group of this study.
Length of survival showed that 8 newborns died after 28 days;
therefore no longer during the neonatal period. Neonatal mortality
and early neonatal mortality rates are comparable to the those
observed in the city of São Paulo in 2001: 9.78%0 e 6.85%0,
respectively (SEADE, 2001)(9). HGG serves patients at higher risk
for being a reference hospital and providing services to a population
that presents higher LBW rate than that observed in the health
district it is located in. Neonatal mortality rates were lower than
those observed in the health district, probably because HGG is a
teaching hospital, with better resources.
Neonatal anoxia, classified by 1-minute Apgar score, was
related to both early and later mortality(17).
The prevalence of anoxia seems to be related to socioeconomic
level of the population, reflecting their health conditions, prenatal
care, and delivery conditions. Anoxia and severe anoxia rates at
MEVCN, in 1990, were 22.7% and 3.7%, respectively(12), whereas
at HIAE, the rates were 4.4% and 0.7%, respectively, in 2002(13).
The population assessed in the present study showed rates that
are intermediate when compared to those previously mentioned.
Severe anoxia and mortality were significantly associated.
The relation between poor obstetric results and no use of
prenatal care services has been demonstrated in many aspects, such
as intrauterine malnutrition(11) and mortality(8,11,14-15). Scholl(18)
reports that 52% of pregnant women attend less than 3 prenatal
care consultations. Brazilian studies show that more than 89% of
pregnant women undergo some kind of control (19), a higher
percentage than that observed in our service. Several factors could
be affecting prenatal care, including the prevalence of adolescent
mothers who, very often, conceal pregnancy. The quality of
prenatal care is also an important factor associated with
mortality(18).
The fact that most deaths were of neonates born at
gestational age < 35 weeks could suggest that premature
delivery could affect the number of prenatal care consultations.
Mayorga(8) reported mothers of VLBW neonates attended an
average of 3.6 appointments, showing the need of larger
investments in encouraging and recruiting patients, and
providing such service to them.
Assessing the causes of death and taking into consideration
maternal and delivery history, it was possible to distinguish
neonates born with infection who died for this reason from those
who died due to nosocomial infection. However, in both cases, the
death certificates report septic shock as the cause of death, with
no distinction.
einstein 2003; 1:9-13
The cause of death of all newborns with birth weight > 2,000 g
was malformation or severe anoxia. Malformation rate observed
in this analysis was the same observed by Sarinho (20), who evaluated
the basic causes of death in his study.
Anoxia was the single cause of death of two neonates who were
not VLBW and lived for one day. A similar rate was observed by
Sarinho(20). The premature death prevented the onset of localized
symptoms observed in other newborns, such as meconium
aspiration syndrome, necrotizing enterocolitis, hypoxic-ischemic
encephalopathy, and acute renal failure.
The analyses of medical charts enabled classifying death as
avoidable or unavoidable within the hospital setting. The following
factors were evaluated: interval from mother’s admission to
hospital and delivery, severity of anoxia, length of survival, presence
of malformations, and appropriate treatment. It must be pointed
out that many of those deaths considered avoidable occurred due
to complications associated to therapeutical procedures, which
were essential for neonatal survival and determined by some
technical restrictions.
CONCLUSIONS
1. Neonatal mortality rate at Hospital Geral do Grajaú is
comparable to that observed in the State of São Paulo, although
the population served at this setting presents major health
problems.
2. Perinatal anoxia was highly associated to neonatal mortality.
3. Unavoidable causes of death (intrauterine infection associated
with severe anoxia and prematurity; malformations incompatible with life) accounted for 64.0% of neonatal deaths during
the period studied.
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