INTRODUCTION

Perinatal mortality has been a matter of concern and discussion on the part of entities and organizations involved in comprehensive child health care. This was included in the Millennium Development Goals (MDG), a commitment assumed by member countries of the United Nations (UN), to which Brazil is a signatory, since infant mortality reflects the living conditions of society¹, and the Sustainable Development Goals (SDG 3), which calls on member countries to end under-5 mortality by 2030².

Historically, it is possible to highlight initiatives that positively impacted care for pregnant women and newborns, such as: the alignment of public policies, the organization of services, the systematization of care proposed by the Brazilian Ministry of Health, through initiatives such as Rede Cegonha (Stork Network) and the regulations introduced by the Diretrizes Nacionais de Assistência ao Parto Normal (National Guidelines for Assistance to Normal Childbirth), as well as the document proposed by the Sociedade Brasileira de Pediatria para o Nascimento Seguro (Brazilian Society of Pediatrics for Safe Birth). These initiatives have brought irrefutable benefits in reducing perinatal mortality. However, it is necessary to advance in confronting these issues, based on comprehensive care and the implementation of a prevention paradigm^3,4.

The perinatal period was initially defined by the World Health Organization (WHO) in the eighth revision of the International Classification of Diseases (ICD-8) in 1967, as that between the 28th week of gestation or children weighing over 1,000 g to the seventh day of life. With the ICD-10, edited in 1993 and adopted in Brazil in 1996, this period begins in the 22nd week of pregnancy and considers children weighing over 500g⁵.

According to the Brazilian Ministry of Health, the perinatal mortality rate is the number of deaths occurring in the perinatal period per thousand total births, in the population residing in a given geographic area, in the year considered⁶.

It is estimated that there are 4.9 million perinatal deaths per year in the world, 2 million of which are fetal and 2.9 million are early neonatal. In Brazil, between 2001 and 2015, the perinatal mortality rate changed from 22.3 to 17.4 per thousand births, with the southern region having the lowest rate and the northeast the highest, with values of 15.4 and 21.2, respectively^6-8.

Several authors point out risk factors associated with perinatal mortality, evidencing avoidable causes closely related to the quality of care, ranging from situations arising from the quality of prenatal care, delivery and newborn care^6-10.

With the identification of risk factors for perinatal mortality, it becomes tangible to reflect on the quality of care provided to pregnant women and their fetus. Thus, enabling the planning of actions to confront and propose public health policies that impact on the reduction of maternal and child mortality indicators¹¹.

In this context, considering the relevance of the topic, this study aims to analyze the perinatal mortality rate in the metropolitan region of Vitória, Espírito Santo, and to identify factors associated with deaths in the period between 2008 and 2017.

METHODS

This is an ecological study with a quantitative approach. The study site was the Metropolitan Region of Greater Vitória in the State of Espírito Santo, Brazil, which covers the municipalities of Cariacica, Fundão, Guarapari, Serra, Viana, Vila Velha and Vitória.

The study population consisted of perinatal deaths (fetal and early neonatal) in the cities of the Metropolitan Region of Greater Vitória, Espírito Santo, Brazil, and the total number of live births in this period. The concept of perinatal mortality rate was defined in accordance with the Brazilian Ministry of Health¹², which considered the number of fetal deaths from 22 complete weeks of gestation (154 days) plus deaths occurring up to the seventh day of life, per thousand total births (fetal deaths plus live births), in period, in the considered geographic space.

For this study, perinatal mortality was considered as a dependent variable. The independent variables consist of the types of deaths (fetal/non-fetal), year of occurrence, municipality of residence, underlying cause of death, sex, place of death (home, hospital, other health facilities, public road), education of mother, type of pregnancy, type of delivery and birth weight.

Data were extracted through the Sistema de Informação sobre Mortalidade (Mortality Information System/SIM) and Sistema de Informações sobre Nascidos Vivos (Information System on Live Births/SINASC) of the Espírito Santo State Health Department to prevent underreported results and inconsistency regarding the updating of data in these systems.

In the statistical analysis to assess the trend of perinatal mortality, regression models were used, with the mortality rate (dependent variable - Y) and time (independent variable - X) expressed in the years that make up the period as the dependent variable in the study period (2008 to 2017). The trend was also estimated with national standardized rates for each location and age group, with a confidence level of 95% and the statistical program used was the Data Analysis and Statistical Software for Professionals (Stata) version 16.0^®.

The study was approved on June 26, 2018, by the Research Ethics Committee of the Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória – CAAE 89718218.6.0000.5065, under opinion number 2.738.639, and complies with the prerogatives of the resolution 466/12 of the National Health Council (CNS) regarding research with human beings.

RESULTS

The total number of live births between the years 2008 to 2017 was 273,611 in the Metropolitan Region of Greater Vitória (RMGV). Deaths in this same period were equivalent to 4,003.

According to figure 1, it is possible to verify the perinatal mortality rates in the RMGV between the years 2008 to 2017. There is an irregular distribution along them, highlighting the higher number of cases per thousand live births in the years of 2011 (16.11) and 2015 (15.38), contrasting a decline in the number of cases in the years 2010 (14.00), 2014 (13.99) and 2017 (13.90).

Figure 1 : Perinatal mortality between the years 2008 to 2017 in the Metropolitan Region of Greater Vitória 

Regarding the comparison of municipalities in the years 2008 to 2017, it is observed that there were no significant changes in the mortality rate between the municipalities according to the p value found in the statistical analysis of logistic regression, as shown in table 1.

The municipality of Vitória has the lowest mortality rate variability in relation to the others and has the best performance in the analysis, reaching an average of 9.12 deaths per 1000 live births in 2014. However, the municipality of Fundão stands out, with a mortality rate of 31.25 and 38.79 per 1000 live births, in the years 2008 and 2016, respectively, which shows an ascendancy in the graphic line. From 2009 to 2010, also in the municipality of Fundão, there was a marked reduction in the perinatal mortality coefficient, from 16.81:1000 to 3.60:1000.

As for the other municipalities, the trend was maintained in the longitudinal distribution, with emphasis on the municipality of Guarapari, which showed an increase in the number of deaths between the years 2010 to 2013.

It is observed that among the neighborhoods of the analyzed municipalities, deaths are concentrated in low economic class neighborhoods with greater inequality or more populous neighborhoods. Except for the municipalities of Guarapari and Vitória, all had more deaths in neighborhoods with greater inequalities (table 2).

Among the characterization of deaths, it is observed that most mothers had between 8 and 11 years of education (39.9%), the most common birth was vaginal (53.59%) and they had an average age of 26.9 years, having approximately an average of 1.8 living children. As for the characteristics of the fetus, fetal deaths (63.14%) stand out from non-fetal deaths (36.86%), in which 54.19% were male and of those identified by race, 24.59% were brown, as shown in the table below.

With regard to the underlying causes of perinatal deaths in the RMGV, it was identified that the Fetus and Newborn Affected by Complications of the Placenta, Umbilical Cord and Membranes was the most incident, with 25.99% of total deaths, followed by Fetus and Newborn Affected by Maternal Disorders, Not Mandatory Related to Current Pregnancy, with 25.14% and intrauterine hypoxia with 8.60%. Regarding the causes of less frequent deaths, there are congenital malformations, aggression by sharp or penetrating and blunt objects, among others (table 4).

DISCUSSION

The distribution of deaths was not homogeneous in the municipalities in the RMGV. Even so, the perinatal mortality rate did not show a significant change between the years 2008 to 2017 in the Metropolitan Region of Greater Vitória. However, it is noted that the rates are lower when compared to the Brazilian reality in 2010, when it reached 21.05/1000 births, and above developed countries, which reached an average of 2 to 7:1000 births. The US fetal mortality rate was 5.96 in 2013 and 6.05 in 2012¹³.

The municipality of Vitória had the lowest perinatal mortality rates during the study period. The city is the capital of the State of Espírito Santo, and it is home to hospitals and health services with the highest levels of complexity. According to the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics) (2010), the municipality’s human development index was 0.845 and considered the fourth best in the country, which may explain the better result associated with the perinatal mortality rate¹⁴. Furthermore, in Vitória, the registration of prenatal care is carried out through the Prenatal Clinical File and inserted within the Well-Being Network, which is a computerized system of the health care network of the Municipal Health Department. of the municipality. A survey conducted in the state of Santa Catarina on perinatal mortality, in the southern region of the country, describes those good coefficients may be associated with greater access to and structuring of health services and favorable social conditions, such as less inequality, work, income and education when comparing the reality in the national territory¹⁵.

Although Fundão is in the RMGV, according to Almeida and Szwarcwald¹⁶, health services in Brazil are concentrated in urban areas, capitals, and central areas, to the detriment of rural areas, less favored and peripheral areas. There is, together with socioeconomic and cultural factors, great inequality in the supply and greater difficulty in accessing health services, due to the concentration of establishments with obstetric beds in large cities.

Furthermore, in agreement with the finding, a survey carried out in the city of Rotterdam, Netherlands, identified that children of women who lived in less favored neighborhoods were 1.8 more likely to die, compared to children of women who lived in more economically favored neighborhoods. This increase was related to socioeconomic factors, demographics, lifestyle, and the quality of obstetric care offered¹⁷.

Regarding the underlying causes of death, it is noted that in this study, the three causes with the highest number of occurrences are complications of the placenta, umbilical cord and limbs and maternal affections, not necessarily related to the current pregnancy, and intrauterine hypoxia.

Most were maternal causes, with a significant number, totaling 68.16% of deaths, and most cases are feasible situations to be addressed with access to health services, quality prenatal care and safe birth, demanding public health policies possible to be implemented. Of these, it was identified that perinatal outcomes due to maternal causes, hemorrhages (especially placental abruption) and hypertensive diseases (especially pre-eclampsia) are the most likely to have death as an outcome, especially third trimester fetal ones¹⁸.

Other studies showed results similar to these, with 22.71% of fetal deaths having intrauterine hypoxia as the registered cause and 20.8% as death without explanation¹⁹. Jacinto et al.²⁰ found intrauterine hypoxia as the cause of fetal death in 44.7% of cases.

Linking to the underlying causes of perinatal deaths in the study, placental complications, vaginal bleeding caused by placental abruption or placenta previa is associated with a very high risk of preterm delivery. In addition, other common reasons for indicated premature births include pre-eclampsia or eclampsia and intrauterine growth restriction. Births following spontaneous preterm labor are considered a syndrome resulting from multiple causes, including infection or inflammation, vascular disease, and over-distension. Premature birth remains one of the leading causes of perinatal morbidity and mortality worldwide²¹.

The causes of perinatal mortality due to prematurity are potentially preventable and need to have their determinants identified in order to propose efficient measures for their prevention. To better understand the changes in the causes of premature birth, it is necessary to address the quality of prenatal care and delivery²².

In this context, the relevant role played by fetal death investigation committees is highlighted, which are increasingly acting in Brazil. A survey carried out at the Regional Health Unit of Belo Horizonte, Minas Gerais, Brazil, pointed out that the implementation and performance of the committees occurred differently in the different municipalities that comprise it, noting that those municipalities that had their implementation earlier had better indicators. This fact supports the prerogative that the implementation of public health policies and organization of services are essential to improve the morbidity and mortality conditions of populations²³.

Considering causes related to newborns, Congenital Malformations Not Classified Elsewhere, showed an important representation, being these of different etiologies, cardiac, renal, central nervous system, pulmonary and others, consequent or not of genetic alterations, which represented Another important cause of death, it is noteworthy that deaths related to fetal causes are difficult to approach and require, in most cases, specialized treatment and a tertiary health care network. In a spatial aggregation study carried out in Salvador by Nascimento et al.²⁴, the authors identified that congenital anomalies and ill-defined causes were responsible for 6.3% and 1.5% of the causes of perinatal death, respectively.

Regarding the low rates of congenital malformations, deformities and chromosomal anomalies compared to other causes of perinatal death, it should be considered that the study is carried out in an emerging country. In developed countries, these conditions have a proportionally higher value of perinatal deaths, due to the low percentage of deaths from preventable causes²⁵.

It is also worth mentioning that the percentage of unspecified and ill-defined fetal deaths is still frequent, also, in other studies. This group can infer that there is difficulty in accessing or precarious health care. However, if the number of deaths classified as ill-defined increases, the quality of the study data may be compromised. However, these causes tend to decrease, as health policies focused on the investigation of infant deaths have been implemented throughout the country²⁶.

Thus, it is important to assess all deaths in order to find the cause and adopt preventive measures. Thus, it is clear that the methods of evaluating deaths have positive and negative aspects, but the analysis of each one is essential for investigating deaths and for evaluating the quality of health services provided in the region²⁶.

In view of the results obtained, it is worth emphasizing the relationship between the proportion of neonatal deaths in the first hours of life and that of fetal deaths with the quality of care offered in the pregnancy-puerperal cycle of women. Therefore, to reduce infant and perinatal mortality, greater efforts are needed so that health actions reflect improved access and quality of care²⁷.

Comprehensive care for patients is essential and corresponds to humanized care that is directly associated with health promotion and disease prevention. Aspects such as equity, development, partnerships, participation, bonding, as well as effective public policy strategies contribute to the reorientation of public health service practices, accountability of all involved and finding solutions for complications²⁸.

Thus, to achieve the millennium goals, it is necessary to expand child health interventions in several places. One way to support the process is to increase the monitoring of deaths and promote correct registration. In addition, it is necessary to know the underlying causes and strengthen information systems, so that in the near future, estimates of infant mortality in the country can be improved²⁹.

A limitation found in the study was the possible occurrence of underreporting of births and deaths or the existence of blank and ignored variables. There may also be errors and difficulties in filling in the variables, such as the newborn’s race/color that is reported by the mother or observed by the professional who collects the data, or situations of birth weight and Apgar score, incompatible with the week of pregnancy.

The Brazilian Ministry of Health establishes the mandatory surveillance of infant and fetal deaths in services that make up the Sistema Único de Saúde (Unified Health System/SUS), in accordance with Ordinance No. 72 of the Ministry of Health, of January 11, 2010. All notifications must have their fields filled in with the information from the Death Certificate, to assist in the investigation of cases³⁰.

Still, there are problems with perinatal mortality records, although most of these deaths occur in hospital units. There is, underreporting and lack of relevant information to obtain specific indicators, such as the percentage of intrapartum deaths. In the vast majority of federation units, it is not yet possible to directly calculate perinatal mortality rates by the Sistema de Informação de Mortalidade (Mortality Information System/SIM)³¹.

There were no significant changes in mortality rates in the Metropolitan Region of Greater Vitória. The municipality of Fundão had the highest rate compared to other municipalities and had an increase in the years 2008 and 2016, and this is also the municipality in the analyzed region that is located more peripherally to the state capital, Vitória, also having the least number of services of health.

The three causes with the highest number of deaths were complications of the placenta, umbilical cord and membranes and maternal affections, not necessarily related to the current pregnancy and intrauterine hypoxia.

CONCLUSION

There were no changers in mortality rates in the Metropolitan Region of Geater Vitória. The municipality of Fundão had the highest rate detected compared to the other municipalities and had an increase in the years 2008 and 2016, and this is also the municipality in the region that is located more peripherally to the state capital, Vitória, also having the lowest amount of health care services. The three causes with the highest number of deaths were complication of the placenta, umbilical cord and membranes and maternal condition not necessarily related to the current pregnancy and intrauterine hypoxia.