ORIGINAL ARTICLE https://doi.org/10.

1590/1984-0462/2023/41/2021302

Neonatal near miss and mortality and associated

factors: cohort study of births in the city of
Rio de Janeiro, RJ, Brazil
Near miss e mortalidade neonatal e fatores associados: estudo
de coorte de nascimentos do município do Rio de Janeiro, RJ
Narayani Martins Rochaa,* , Pauline Lorena Kalea , Sandra Costa Fonsecab ,
Alexandre dos Santos Britoa

ABSTRACT RESUMO
Objective: The aim of this study was to investigate factors Objetivo: Investigar fatores associados aos near miss e óbito
associated with neonatal near miss and mortality of the live birth neonatais na coorte de nascidos vivos do município do Rio de
cohort in the city of Rio de Janeiro, Brazil, in 2015. Janeiro (RJ), 2015.
Methods: Population-based retrospective cohort of live births Métodos: Coorte retrospectiva de base populacional de
(LB) of single pregnancy with 0–27 days of follow-up. Data were nascidos vivos de gravidez única com seguimento de até 27
obtained from the Brazilian Live Birth and Mortality Information dias. Dados obtidos dos Sistemas de Informações sobre Nascidos
Systems. Logistic regressions with the analytical strategy of Vivos e sobre Mortalidade. Foram usadas regressão logística e
hierarchical determination were used for cases of near miss and estratégia analítica de determinação hierárquica separadamente
deaths separately. para casos de near miss e óbitos.
Results: The cohort was composed of 85,850 LB. For every one Resultados: Coorte composta de 85.850 nascidos vivos. Para cada
thousand LB, about 16 were cases of near miss and six died. mil nascidos vivos, 16 foram casos de near miss e seis evoluíram
Maternal level of education, skin color, and age and adequacy para óbito. Escolaridade, cor da pele e idade maternas e adequação
of prenatal care were associated with neonatal near miss; for do pré-natal estiveram associadas ao near miss neonatal; para
deaths, presentation of LB at delivery, birth weight, gestational óbitos, acrescenta-se apresentação do NV no parto, peso, idade
age, and five-minute Apgar score are added. gestacional e Apgar no 5º minuto.
Conclusions: Besides confirming the effect of low birth weight, Conclusões: Além de confirmar o efeito do baixo peso, da
prematurity, and asphyxia on neonatal death, socioeconomic prematuridade e da asfixia no óbito neonatal, variáveis marcadoras
vulnerability markers – low education level and brown or black de vulnerabilidade socioeconômica — baixa escolaridade e cor
skin colors – were associated with neonatal death and near da pele parda ou preta — mostraram-se associadas ao óbito e ao
miss. Absent or inadequate prenatal care showed a strong near miss neonatal. Pré-natal ausente ou inadequado mostrou
association with both outcomes, being stronger for neonatal forte associação com ambos os desfechos, mais intensa para o
death. Investments in the quality of prenatal care and reduction óbito. Investimentos na qualificação do pré-natal e na redução
of disparities in health care are necessary in Rio de Janeiro. das desigualdades na saúde são necessários no Rio de Janeiro.
Keywords: Near miss; Neonatal mortality; Prenatal care; Information Palavras-chave: Near miss; Mortalidade neonatal; Cuidado pré-
systems; Maternal and child health. natal; Sistemas de informação; Saúde materno-infantil.

*Corresponding author. E-mail: narayanimartins@gmail.com (N. M. Rocha).

a
Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
b
Universidade Federal Fluminense, Niterói, RJ, Brazil.
Received on August 29, 2021; approved on December 08, 2021.
Neonatal near miss and mortality and associated factors

INTRODUCTION Mortality Information System (Sistema de Informações sobre

Neonatal death and near miss, severe negative outcomes, Mortalidade – SIM) of the Municipal Health Department of
are related to pregnancy, delivery, and newborn conditions, Rio de Janeiro (Secretaria Municipal de Saúde do Rio de Janeiro
reflecting the quality of health care.1,2 There are still few stud- – SMSRJ). The linkage of the respective databases was deter-
ies evaluating sociodemographic conditions, with discordant ministic when information on the number of the LB certificate
results, especially regarding the maternal level of education was completed on the death certificate; and, in its absence, it
and skin color.3-7 was probabilistic, considering the date and institution of the
In a national meta-analysis of factors associated with neo- newborn’s birth and maternal name and date of birth.
natal death, the following maternal variables stand out: absence All LB weighing ≥500g and with GA ≥22 weeks were eli-
of a partner, age ≥35 years, multiple pregnancy, absence or gible for the study. Multiple-pregnancy LB were excluded due
inadequacy of prenatal care, complications during pregnancy, to differentiated risks of morbidity and mortality15 and with
and cesarean delivery. The following factors are related to new- inconsistencies between BW and GA information (values other
borns: male sex, congenital malformation, perinatal asphyxia, than those of the following ranges of the lowest 3rd percen-
low birth weight, and prematurity.3 tile value and the highest 97th percentile value of weight for
Neonatal near miss (NNM), defined as the situation of GA): 22 weeks (500–930g); 23 weeks (500–1030g); 24 weeks
being born with life-threatening conditions and surviving, (500–1160g); 25 weeks (500–1260g); 26 weeks (500–1380g);
has been studied,1,2,8 but still without a universal definition.9-12 27 weeks (580–1520g); 28 weeks (620–1670g); 29 weeks
Strong predictors of neonatal death are used as criteria to define (670–1840g); 30 weeks (740–2070g); 31 weeks (860–2420g);
life-threatening conditions.9 Birth weight (BW), gestational 32 weeks (1100–2830g); 33 weeks (1180–3220g); 34 weeks
age (GA), and five-minute Apgar score are present in different (1350–3500g); 35 weeks (1550–3500g); 36 weeks (1790–
NNM definitions, and are considered pragmatic criteria, as 3820g); 37 weeks (2040–4000g); 38 weeks (2250–4350g);
they correspond to easily measured and available information. 39 weeks (2400–4600g); 40 weeks (2490–4875g); 41 weeks
These criteria, alone or accompanied by clinical, laboratory, (2560–5000g); and 42 weeks (2600–5000g).16,17
and management criteria, compose the definition of NNM, LB were classified according to life-threatening conditions
validated in national studies.1,10,11,13 at birth: presence of at least one of the pragmatic criteria of
Although there are still few national studies on factors associ- the NNM definition according to the Nascer no Brazil (Birth
ated with NNM, the results are similar. Maternal age ≥35 years,5-7 in Brazil) study:10 GA<32 weeks or BW<1500g or five-minute
black skin color and absence of a partner,7 morbidities in preg- Apgar score<7. Life-threatening births and neonatal survivors
nancy – such as hemorrhage, hypertensive diseases,5-7 diabetes,5,6 corresponded to the valid definition of NNM cases solely based
urinary tract infection,6 and syphilis –,7 smoking habit,6 use of on pragmatic criteria.11
illicit drugs,7 inadequate prenatal care,5,7 delivery in a public hos- The following aspects were estimated: proportion of
pital,4 pilgrimage for delivery,14 and cesarean delivery,4,5 among life-threatening births at birth, rates of NNM per one thou-
others, are important determinants of NNM cases. sand LB (NNMR: quotient between the number of NNM cases
The present study aimed to investigate factors associated and total LB), neonatal mortality (NMR: total, early, up to six
with neonatal near miss and death in the population-based days, and late – from seven to 27 days), and severe outcomes
cohort of live births in the municipality of Rio de Janeiro, state (quotient between the sum of NNM cases and neonatal deaths
of Rio Janeiro (RJ), Brazil, in 2015. by total LB) and respective 95% confidence intervals (95%CI).
In addition, the mortality rate (%) (quotient between neona-
tal deaths of LB with life-threatening conditions and the total
METHOD number of LB with life-threatening conditions) and the ratio
This is a retrospective cohort of live births (LB), children of between NNM cases and deaths (quotient between NNM
residents of Rio de Janeiro, in 2015. The follow-up time cor- cases and neonatal deaths per one hundred) were calculated.
responded to the neonatal period (27 full days), and negative The maternal variables (SINASC) were grouped into:
outcomes were NNM cases and deaths. • sociodemographic (age group: <20, 20–34, and ≥35
Data on live births were obtained from the Brazilian Live years; ethnicity/skin color: white, black, brown, and
Birth Information System (Sistema de Informações sobre Nascidos others; level of education: <4, 4–11, and ≥12 years of
Vivos – SINASC), in 2015; and data on neonatal deaths (which formal education; have a partner: yes vs. no);
occurred from January 1, 2015 to January 27, 2016 and those • reproductive (number of deceased children: 0 vs. ≥1;
who were born in 2015) were obtained from the Brazilian number of living children: 0, 1–3, and ≥4);

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 Rocha NM et al.

• pregnancy and delivery (prenatal care: no prenatal care, For the outcomes, the variable “sex of the live birth,” which
onset at the ≤3rd month or >3rd month; presentation of does not belong to hierarchical levels, was independently
the newborn: cephalic, breech, and transverse; type of addressed, without adjustments. The variable “type of delivery”
delivery: vaginal vs. cesarean delivery); was not included due to the possibility of indication bias in the
• newborn (sex: male vs. female; BW: <1500g, 1500–2499g, associations studied with severe neonatal outcomes.
2500–3999g, and ≥4000g; GA: <32, 32–36, 37–39, and To describe the cohort, proportions were calculated for
≥ 40 weeks; five-minute Apgar score<7 vs. ≥7). categorical variables, according to severe negative outcome.
Pearson’s chi-square or Fisher’s exact tests were used to test the
As most NNM cases met the pragmatic criterion of homogeneity of the population.
GA<32 weeks, the proposal of adequacy of access to prena- For the analysis of factors associated with the outcomes,
tal care of the Brazilian Ministry of Health was adapted:18 the binary logistic regression models were employed. After per-
number of consultations was not considered, only if the preg- forming crude analyses, covariates with p<0.20 were selected
nant woman received prenatal care and, in this case, the onset for the multiple regression model of the respective hierarchical
trimester. Likewise, considering the independent effect of GA level. Only variables with p <0.05 of the multiple regression
on breech presentation during delivery in preterm infants,12 were maintained in the final model. Covariates of the same
this variable was not evaluated for NNM, only for mortality. hierarchical and previous levels were deemed as possible con-
Factors associated with each outcome were investigated separately, founding factors.
based on theoretical models of hierarchical determination – distal, The present study was approved by the Research Ethics
intermediate, and proximal factors – of the severity of the newborn’s Committees of the Institute of Collective Health Studies of
condition,7 adapted according to the availability of information. Universidade Federal do Rio de Janeiro (No. 2.105.885) and the
In the model for NNM, the distal hierarchical level comprised SMSRJ (No. 2.218.098). The linkage of databases was performed
the maternal variables ethnicity/skin color (white, black, and in the SMSRJ, and they were transferred without identification.
brown, with “others” being excluded due to the low frequency of
LB) and level of education (<8 vs. ≥8 years of formal education).
These variables were adjusted between each other and followed RESULTS
to the intermediate level without being adjusted for the other The cohort comprised 90,535 LB, of which 90,448 were eli-
variables. The intermediate level included maternal age (<20, gible (Figure 1). With the exclusion of twins and losses due
20–34, and ≥35 years), having a partner (yes vs. no), and parity to inconsistencies between BW and GA (5.1%), the number
(primiparous vs. multiparous). Subsequently, they were adjusted of LB decreased to 85,850, of which 1.3% were not classified
between each other and for those at the distal level, which were according to life-threatening conditions due to lack of infor-
significant, following to the proximal level. Finally, the proxi- mation (except for BW, 100% completeness).
mal level comprised prenatal care adequacy (no prenatal care, Among newborns with the presence of at least one prag-
onset at the first trimester and after the first trimester), which matic neonatal near miss criterion (<32 weeks; BW<1500g,
was adjusted for all variables that were previously significant. or five-minute Apgar score<7), 1,404 were classified as NNM
In the model for neonatal death, the maternal variables eth- cases, and 254 died. Among the 83,099 LB without any of the
nicity/skin color (white, black, and brown) and level of educa- life-threatening criteria, 127 died, 33.9% due to congenital
tion (<8 vs. ≥8 years of formal education) composed the distal malformation, a value 2.3 times higher than the frequency of
level. The intermediate level was divided into two subgroups: the same cause among deaths with life-threatening conditions.
• intermediate I: maternal age (<20, 20–34, and ≥35 years), In addition, there were 128 deaths not classified according to
having a partner (yes vs. no), and parity (primiparous life-threatening conditions, due to ignored information on
vs. multiparous). five-minute Apgar score and GA, totaling 509 deaths (Figure 1).
• intermediate II: prenatal care adequacy (no prenatal care, Among the deaths not classified according to life-threatening
onset at the first trimester and after the first trimester), and conditions, 91.4% were between 1500 and 2500g and 6.3%
newborn presentation at delivery (cephalic: yes vs. no). were due to congenital malformation.
The indicators of serious outcomes are shown in Figure 2.
The proximal level was composed of newborn variables: pre- For every one thousand LB, 16 were NNM cases, six died,
maturity (<37 weeks: yes vs. no), low birth weight (<2500g: yes four being early neonatal deaths and two, late neonatal deaths.
vs. no), and five-minute Apgar score<7 (yes vs. no). The hierar- The ratio of NNM cases and deaths was 2.8, that is, there were
chical approach followed the same steps described for the NNM. three cases of NNM for each death.

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Neonatal near miss and mortality and associated factors

Cohort of resident live births

90,535

Ineligibility (<22 weeks or

<500g) 87 live births (1%)

90,448 live births (97%) Exclusions: multiple pregnancy

or ignored type of pregnancy
2,151 live births (2.4%) and
inconsistency between BW and
85,850 live births (94.9%) GA 2,588 live births (2.9%)

With LTC No LTC Ignored LTC

1,658 (1.9%) 83,099 (96.8%) 1,093 (1.3%)

NNM Cases Deaths Survivors Deaths Survivors Deaths

1,404 (84.7%) 254 (15.3%) 82,972 (99.9%) 127 (0.1%) 965 (88.3%) 128 (11.7%)

BW: birth weight; GA: gestational age; LTC: life-threatening conditions; NNM: neonatal near miss.

Figure 1 Cohort of live births, municipality of Rio de Janeiro (RJ), Brazil, 2015.

The distribution of LB per sociodemographic, reproductive, Regarding the hierarchical determination of neonatal death,
pregnancy, childbirth, maternal, and newborn variables and accord- except for the “parity” variable, all the others were strongly
ing to severe outcome is shown in Tables 1 and 2. Ignored infor- associated in the crude analysis (Table 4). The variable “have
mation ranged from 0 to 3.7%. Regardless of the negative out- partner,” when adjusted, showed no significant association.
come, young mothers (<35 years), with level of education between The adjusted odds ratios (OR), when compared with unad-
four and 11 years of formal education, brown skin color, with- justed values, were lower, except for those aged ≥35 years, which
out a partner, multiparous, with the onset of prenatal care during increased (negative confounding). Intermediate II and proxi-
the first trimester, and who had cesarean delivery predominated. mal variables showed greater strength of association with death,
Conversely, survivors without life-threatening conditions, NNM even after confounding control, with emphasis on no prenatal
cases, and deaths were heterogeneous according to the analyzed care (ORadjusted=6.5), non-cephalic presentation (ORadjusted=5.6),
variables, except for parity and type of delivery (Tables 1 and 2). five-minute Apgar score<7 (ORadjusted=29.5), weight<2500g
Considering the increasing gradient of severity of outcomes, there (ORadjusted=8.1), and prematurity (ORadjusted=4.6).
was an increase in the proportion of adolescent mothers, brown
and black women, without a partner, previous deceased children,
non-prenatal care, and non-cephalic presentation. DISCUSSION
The regression models for the NNM outcome are demon- In the Rio de Janeiro LB cohort of 2015, sociodemographic
strated in Table 3. In the crude analysis, with the exception of factors related to prenatal care, delivery, and the newborn were
“sex,” all variables were associated with NNM (p<0.20), and in strongly associated with severe negative neonatal outcomes.
the adjusted analysis, only the category of adolescents was not Burdens of severe morbidity and neonatal mortality pointed
maintained (considering p<0.05). At the distal level, the chance to a more adequate scenario in the municipality in 2015
of being a case of NNM was higher in children of black mothers (NNMR=16 and NMR=5.9 per one thousand LB), when com-
with low level of education; and at the intermediate level, chil- pared with 2012.19 NNM and mortality rates decreased by 3.5
dren of older women and those without a partner. The adjusted and 0.8 per one thousand LB, respectively. Both the present
strength of association greater than 3 between prenatal care adequacy study (LB cohort of 2015) and the study conducted on the
(“no prenatal care” category) and the NNM outcome stands out. LB cohort of 201219 are single-pregnancy LB cohorts and used

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 Rocha NM et al.

* per 1,000 Live births

0 2 4 6 8 10 12 14 16 18 20 22 24

Neonatal near miss rate*

16.6 (95%CI: 15.7-17.4)

Neonatal mortality rate*

5.9 (95%CI: 5.5-6.5)

Early neonatal mortality rate*

4.1 (95%CI: 3.7-4.6)

Late neonatal mortality rate*

1.8 (95%CI: 1.6-2.2)
Rate of severe neonatal outcomes
(near miss and death)*
22.6 (95%CI: 21.6-23.6)

Neonatal mortality index**

15.3 (95%CI: 13.7-17.1)
Proportion of live births with
life-threatening conditions
2.1 (95%CI: 2.1-2.3)

0 2 4 6 8 10 12 14 16 18 20 22 24
** per 100 Live births

per one hundred live births per one thousand live births 95CI%: 95% confidence interval

95%CI: 95% confidence interval.

Figure 2 Indicators of severe negative neonatal outcomes. Cohort of single-pregnancy live births in the city of Rio
de Janeiro (RJ), Brazil, 2015. Source: SIM/SINASC/SMSRJ.

the same definition of NNM. In 2012, in the city of Joinville and the NMR, 4.1 per one thousand LB (respectively ranging
(state of Santa Catarina, Brazil),4 NNMR (33 per one thou- from 3.7 to 30.5 per one thousand LB, and from 1.9 to 14.4
sand LB) was higher, and NMR (4.5 per one thousand LB) was per one thousand LB among the six participating institutions).7
lower than in Rio de Janeiro, suggesting lower-risk births and/ In the national survey on maternity hospitals, NNMR and
or better health care. The Santa Catarina study used popula- NMR were 39.2 and 11.1 per one thousand LB, respectively.10
tion data from SINASC, did not exclude multiparous mothers, The differences between the studies can be explained by the
and adopted the definition of NNM according to Silva et al.10 varied hospital profiles of risk and quality of obstetric and neo-
Most national studies are hospital-based, with higher rates, natal care, by the type of study – hospital- or population-based
especially in public and reference hospitals for high-risk pregnan- –, and exclusion criteria such as multiple pregnancy.4,10,11,13
cies. In the city of Recife (state of Pernambuco, Brazil), in 2012, Additionally, changes in the cutoff points of the pragmatic crite-
the total NNMR was 86.5 per one thousand LB: 112.8 in pub- ria and the addition of other criteria (clinical and laboratory) to
lic hospitals and 28 per one thousand LB in private hospitals.20 the NNM definition resulted in variations in the indicators.4,10,11
In the university hospital of Maceió (state of Alagoas, Brazil), in Regarding the associated factors, the present study corrob-
2015/2016, the NNMR was 220 and the NMR was 57 per one orated the maternal sociodemographic variables, level of educa-
thousand LB.21 In the study on six public maternity hospitals in tion, and skin color. These are important markers of vulnerabil-
the cities of São Paulo (state of São Paulo, Brazil), Rio de Janeiro ity in studies on maternal and child health.22,23 These variables
and Niterói (RJ, Brazil), in 2011, the global NNMR was 17.1 comprised the distal level of the hierarchical models and were

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Neonatal near miss and mortality and associated factors

Table 1 Distribution of maternal sociodemographic and reproductive characteristics, according to severe neonatal
outcomes. Cohort of single-pregnancy live births in the city of Rio de Janeiro (RJ), Brazil, 2015*.
Survivors Deaths
Characteristics No LTC (82,972) Near Miss (1,404) (509) p-valuea
n % n % n %
Age group (years) <0.001
<20 12,682 15.28 254 18.09 103 20.24
20–34 56,280 67.83 881 62.75 309 60.71
≥35 14,010 16.89 269 19.16 97 19.06
Level of education (years) <0.001
<4 1,298 1.56 33 2.35 6 1.18
4–11 59,327 71.50 1,041 74.15 396 77.80
≥12 20,960 25.26 296 21.08 92 18.07
Ignored 1,387 1.67 34 2.42 15 2.95
Ethnicity/skin color b
<0.001
White 30,713 37.02 461 32.83 134 26.33
Black 7,243 8.73 151 10.75 59 11.59
Brown 43,300 52.19 770 54.84 300 58.94
Others 303 0.37 6 0.43 1 0.20
Ignored 1,413 1.70 16 1.14 15 2.95
Have a partner <0.001
No 54,369 65.53 990 70.51 366 71.91
Yes 28,008 33.76 402 28.63 131 25.74
Ignored 595 0.72 12 0.85 12 2.36
Deceased children <0.001
None 67,109 80.88 1,097 78.13 377 74.07
≥1 15,574 18.77 299 21.30 131 25.74
Ignored 289 0.35 8 0.57 1 0.20
Living children 0.002
None 39,310 47.38 594 42.31 225 44.20
1–4 40,727 49.09 759 54.06 266 52.26
≥4 2,934 3.54 51 3.63 18 3.54
Ignored 1 ≈0.0 – – – –
Parity 0.220
Primiparous 35,673 42.99 635 45.23 217 42.63
Multiparous 47,192 56.88 765 54.49 292 57.37
Ignored 107 0.13 4 0.28 – –
*All information was obtained from the Brazilian Live Birth Information System (SINASC), including from deaths after the linkage of databases
(SINASC and the Brazilian Mortality Information System); LTC: Life-threatening conditions; aPearson’s chi-square test, except for level of
education, for which the Fisher’s exact test was used (the “ignored” category of the variables was not considered; only age group presented
100% completeness of the information); bthe homogeneity test for maternal ethnicity/skin color also excluded the “others” category.

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Table 2 Distribution of pregnancy, delivery, and newborn characteristics according to severe neonatal outcomes.
Cohort of single-pregnancy live births in the city of Rio de Janeiro (RJ), Brazil, 2015.
Survivors Deaths
Characteristics No LTC (82,972) Near Miss (1,404) (509) p-valuea
n % n % n %
Prenatal care <0.001
No 565 0.68 33 2.35 25 4.91
Onset≤3rd month 63,497 76.53 980 69.80 328 64.44
Onset>3rd month 18,395 22.17 371 26.42 144 28.29
Ignored 515 0.62 20 1.42 12 2.36
Presentationb <0.001
Cephalic 78,350 94.43 – – 406 79.76
Breech 2,535 3.06 – – 78 15.32
Transverse 202 0.24 – – 6 1.18
Ignored 1,885 2.27 – – 19 3.73
Type of delivery 0.095
Vaginal 36,918 44.49 584 41.60 226 44.40
Cesarean 46,046 55.50 820 58.40 283 55.60
Ignored 8 ≈0.0 – – – –
Sex 0.017
Female 40,582 48.91 667 47.51 217 42.63
Male 42,385 51.08 737 52.49 288 56.58
Ignored 5 ≈0.0 – – 4 0.79
*All information was obtained from the Brazilian Live Birth Information System (SINASC), including from deaths after the linkage of databases
(SINASC and the Brazilian Mortality Information System); LTC: Life-threatening conditions; aPearson’s chi-square test, except for presentation
of newborn (survivors with no LTC and deaths), for which the Fisher’s exact test was used (the “ignored” category of the variables was not
considered; only age group presented 100% completeness of the information); bnear miss cases were excluded from the analysis due to the
independent effect of gestational age on the fetal presentation of preterm newborns12. Source: SIM/SINASC/SMSRJ.

Table 3 Logistic regression models with hierarchical strategy for determining neonatal near miss cases. Cohort of
single-pregnancy live births in the city of Rio de Janeiro (RJ), Brazil, 2015*.
Crude analysis Adjusted analysisa
Hierarchical level/associated factors
p-value OR 95%CI p-value OR 95%CI
Independent
Male 0.303 1.06 0.95 1.17 – – – –
Distal
Black skin color 0.001 1.38 1.15 1.67 0.002 1.34 1.11 1.62
Brown skin color 0.005 1.18 1.05 1.33 0.033 1.14 1.01 1.28
<8 years of formal education 0.001 1.19 1.04 1.35 0.043 1.15 1 1.31
Intermediate
<20 years 0.001 1.28 1.11 1.47 0.314 1.09 0.93 1.27
≥35 years 0.004 1.22 1.07 1.41 <0.001 1.33 1.15 1.54
Primiparous 0.084 0.91 0.82 1.01 0.01 0.86 0.76 0.96
Single <0.001 1.27 1.13 1.42 0.005 1.2 1.06 1.37
Proximal
No prenatal care <0.001 3.71 2.6 5.31 <0.001 3.72 2.57 5.38
Inadequate prenatal care <0.001 1.31 1.16 1.47 <0.001 1.3 1.14 1.48
OR: Odds Ratio; 95%CI: 95% confidence interval; *reference category of the variables: sex of live birth (female), ethnicity/skin color (white),
level of education (≥8 years of formal education), maternal age (20–34 years old), parity (multiparous), have a partner (yes), adequacy of
prenatal care (onset at first trimester); aadjusted ORs were adjusted at the distal level only for the variables of the same hierarchical level; at
the intermediate level, for those of the same hierarchical and previous level; and at the proximal level, for all variables.

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Neonatal near miss and mortality and associated factors

Table 4 Logistic regression models with hierarchical strategy for determining neonatal deaths. Cohort of single-
pregnancy live births in the city of Rio de Janeiro (RJ), Brazil, 2015*.
Crude analysis Adjusted analysisa
Hierarchical level/associated factors
p-value OR 95%CI p-value OR 95%CI
Independent
Male 0.008 1.27 1.06 1.52 0.008 1.27 1.06 1.52
Distal
Black skin color <0.001 1.84 1.35 2.5 <0.001 1.82 1.34 2.49
Brown skin color <0.001 1.57 1.28 1.93 <0.001 1.48 1.2 1.82
<8 years of formal education 0.003 1.37 1.11 1.69 0.048 1.24 1 1.54
Intermediate I
<20 years 0.001 1.84 1.17 1.84 0.031 1.3 1.03 1.65
≥35 years 0.05 1.26 1 1.58 0.009 1.37 1.08 1.74
Primiparous 0.926 1.01 0.85 1.2 – – – –
Singleb 0.001 1.42 1.16 1.74 – – – –
Intermediate II
No prenatal care <0.001 7.55 4.99 11.42 <0.001 6.45 4.15 10.02
Inadequate prenatal care <0.001 1.49 1.22 1.81 0.011 1.32 1.07 1.64
Non-cephalic presentation <0.001 5.73 4.51 7.26 <0.001 5.6 4.35 7.23
Proximal
<2500g <0.001 39.76 32.65 48.41 <0.001 8.06 5.86 11.09
<37 weeks <0.001 28.62 23.37 35.05 <0.001 4.63 3.35 6.41
Five-minute Apgar score<7 <0.001 87.95 72.36 106.88 <0.001 29.54 23.04 37.86
OR: Odds Ratio; 95%CI: 95% confidence interval; *reference category of the variables: sex of live birth (female), ethnicity/skin color (white),
level of education (≥8 years of formal education), maternal age (20–34 years old), parity (multiparous), have a partner, adequacy of prenatal
care (onset at first trimester), newborn presentation at delivery (cephalic), birth weight (≥2500g), prematurity (≥37 weeks), five-minute Apgar
score (≥7); aadjusted ORs were adjusted at the distal level only for the variables of the same hierarchical level; at the intermediate level, for
those of the same hierarchical and previous level; and at the proximal level, for all variables; bin the model adjusted for the variables of the
same hierarchical level and of the previous level, having a partner did not present statistical significance level <0.05 and, therefore, it was not
selected in the analyses of subsequent hierarchical levels.

associated with the outcomes. Some studies found an associ- Advanced maternal age can lead to obstetric complications.25
ation between maternal education and NNM10 and neonatal Women aged 35 years or older were more likely to have a nega-
deaths,7,23 and others did not, such as the one by Pereira et al.,5 tive outcome in the present study, corroborating other studies.3,5,25
in relation to the NNM, and the one by Garcia et al.,24 regard- Only in Maceió21 there was a protective effect of advanced age in
ing death. Maternal skin color was associated with NNM, but relation to NNM, attributed to planned pregnancy and greater
not with death, in the study on maternity hospitals in Rio de prenatal care in these women. The differential of the maternity
Janeiro and São Paulo.7 In the meta-analysis of neonatal death, unit studied in Maceió, a reference for high risk and linked to
skin color was not even included among the evaluated factors.3 the university institution, must be taken into account. Also at the
These disagreements may be related to the analysis models. In the intermediate hierarchical level, absence of a partner and primiparity
hierarchical strategy, these variables are at the distal level and are were associated with NNM, in agreement with other studies.7,26
adjusted only at this level, highlighting their effect more than Failures in the health care provided to pregnant women,
in the analysis in which all variables are adjusted between each addressed in this study in relation to the adequacy of access to
other, regardless of hierarchical relationship. Another explana- prenatal care, still occurred quite frequently and unevenly in
tion is the form of collection, as secondary data is more subject the capital of Rio de Janeiro. Among non-life-threatening sur-
to information biases. Specifically, skin color has been the sub- vivors, the lack of prenatal care was less than 1% and the onset
ject of discussion due to recent changes in the collection means, of prenatal care after the first trimester was 22%. Among the
by self-declaration, adopted by SINASC in 2011. NNM cases, the values were 2.4 and 26.8%, and among the

8
Rev Paul Pediatr. 2023;41:e2021302
 Rocha NM et al.

deaths, 5.7 and 29%. Therefore, a gradient in the severity of Modeling with hierarchical strategy values the representation of
the outcome was observed as the proportion of inadequate distal variables, which may have contributed to the study results.
access increases. The association between prenatal care and The identification of factors associated with NNM and neo-
severe negative neonatal outcomes is consistent with other natal death contributes to the development and implementation
studies.3,5,20,24,26,27 In the national studies10,13 and in Joinville,4 of effective strategies for its reduction. Preventing life-threaten-
adequacy of prenatal care showed no association with NNM. ing births may reduce preventable deaths up to five years in the
The adequacy of prenatal care in these two studies considered municipality of Rio de Janeiro by 97.6%.19 Although survivors
only women who underwent prenatal care, depending on the of the neonatal period, NNM cases present higher mortality up
number of consultations according to GA, and based on the to five incomplete years, especially in the post-neonatal period,19
Prenatal Care and Birth Humanization Program (Programa de permanence of hospitalization for delivery, hospitalization after
Humanização no Pré-Natal e Nascimento – PHPN). discharge from delivery, and weaning in the first year of life,
Regarding the presentation of the newborn at delivery, the evidencing conditions of vulnerability and the need for social
OR was also high, in agreement with hospital-based studies assistance and support for their families.30
conducted in Ethiopia26 and Brazil.27 In the hierarchical deter- Besides confirming the effect of low birth weight, prema-
mination of death, factors of newborns (proximal), BW, GA, turity, and asphyxia on neonatal death, this study identified
and five-minute Apgar score were highlighted, results well-doc- that socioeconomic vulnerability markers — low education
umented in the literature.3,24,27 level and brown or black skin colors — were associated with
The lack of a universal definition for NNM may interfere neonatal death and NNM. Absent or inadequate prenatal care
with the comparison of study results. The authors consider that were strongly associated with both outcomes, being stronger
the pragmatic criteria are the easiest to apply. In addition, we for neonatal death. Investments in prenatal care and reduction
defend the cutoff points of 1500g and 32 weeks, defined in of disparities in health care are necessary in Rio de Janeiro.
the literature as very low birth weight and extremely preterm,
and used to define the severity of perinatal care.28 Funding
Another important issue is a possible underestimation of This study did not receive any funding.
cases and NNM due to unknown or inconsistent informa-
tion. However, among the 2,587 LB excluded, the majority had Conflict of interests
BW≥1500g (94%) and five-minute Apgar score≥7 (97%), with The authors declare there is no conflict of interests.
incompatible GA being the reason for the inconsistency (data not
shown in the table). Therefore, LB small for GA and some LB large Authors’ contribution:
for GA may have been lost, but few cases of NNM. It is known Study design: Rocha NM, Kale PL. Data collection: Rocha NM,
that, of the pragmatic criteria, GA has the lowest reliability.29 Kale PL. Data analysis: Rocha NM, Kale PL. Manuscript writ-
Some of the strengths of the present study were the treatment ing: Rocha NM, Kale PL, Fonseca SC, Brito AS. Manuscript
of the data, with the elimination of inconsistencies between BW review: Rocha NM, Kale PL, Fonseca SC, Brito AS. Study
and GA, and the proper completion of the number of the LB supervision: Kale PL.
certificate on the death certificate, allowing a deterministic link-
age above 90% of the databases. The adaptation of the variable Declaration
“adequacy of access to prenatal care” provided by the Ministry The database that originated the article is available with the
of Health18 is easily applicable and timely for NNM studies. corresponding author.

REFERENCES

1. Pileggi C, Souza JP, Cecatti JG, Faúndes A. Neonatal near a systematic review and meta-analysis of observational
miss approach in the 2005 WHO Global survey Brazil. J studies. J Pediatr (Rio J). 2019;95:519-30. https://doi.
Pediatr (Rio J). 2010;86:21-6. https://doi.org/10.1590/ org/10.1016/j.jped.2018.12.014
s0021-75572010000100005
4. Silva GA, Rosa KA, Saguier ES, Henning E, Mucha F, Franco
2. Surve S, Chauhan S, Kulkarni R. Neonatal near miss review: SC. A populational based study on the prevalence of
tracking its conceptual evolution and way forward. Curr neonatal near miss in a city located in the South of Brazil:
Pediatr Res. 2017;21:264-71.
prevalence and associated factors. Rev Bras Saude Matern
3. Veloso FC, Kassar LM, Oliveira MJ, Lima TH, Bueno NB, Gurgel Infant. 2017;17:159-67. https://doi.org/10.1590/1806-
RQ, et al. Analysis of neonatal mortality risk factors in Brazil: 93042017000100009
9
Rev Paul Pediatr. 2023;41:e2021302
Neonatal near miss and mortality and associated factors

5. Pereira TG, Marano DR, Fonseca VM, Gama SG, Moreira ME. cesárea por critérios de risco epidemiológico a partir do Sinasc.
Factors associated with neonatal near miss in Brazil. Rev In: Health Brazil 2017: an analysis of the health situation and
Saude Publica. 2020;54:123. https://doi.org/10.11606/s1518- challenges to the achievement of the sustainable development
8787.2020054002382 goals. Brasília (DF): Ministério da Saúde; 2018.
6. Martinelli KG, Gama SG, Almeida AH, Pacheco VE, Santos Neto ET. 19. Kale PL, Silva KS, Saraceni V, Coeli CM, Torres TZ, Vieira FM,
Advanced maternal age and factors associated with neonatal near et al. Life-threatening conditions at birth: an analysis of causes
miss in nulliparous and multiparous women. Cad Saude Publica. of death and survival estimate for under-five children in live
2019; 35:1-13. https://doi.org/10.1590/0102-311x00222218 birth cohorts. Cad Saude Publica. 2019;35:e00186418. https://
doi.org/10.1590/0102-311X00186418
7. Kale PL, Mello-Jorge MH, Silva KS, Fonseca SC. Neonatal near
miss and mortality: factors associated with life-threatening 20. Brasil DR, Viela MB, França KE, Sarino SW. Neonatal morbidity
conditions in newborns at six public maternity hospitals in near miss in tertiary hospitals in a capital of northeast Brazil. Rev
Southeast Brazil. Cad Saude Publica. 2017;33:1-12. https://doi. Paul Pediatr. 2019;37:275-82. https://doi.org/10.1590/1984-
org/10.1590/0102-311x00179115 0462/;2019;37;3;00011

8. Say L. Neonatal near miss: a potentially useful approach to 21. Lima TH, Katz L, Kassar SB, Amorim MM. Neonatal near miss
assess quality of newborn care. J Pediatr (Rio J). 2010;86:1-2. determinants at a maternity hospital for high-risk pregnancy
https://doi.org/10.2223/jped.1978 in Northeastern Brazil: a prospective study. BMC Pregnancy
Childbirth. 2018;18:401. https://doi.org/10.1186/s12884-018-
9. Pileggi-Castro C, Camelo JS, Perdoná GC, Mussi-Pinhata MM, 2020-x
Cecatti JG, Mori R, et al. Development of criteria for identifying
neonatal near-miss cases: analysis of two WHO multicountry 22. Kale PL, Fonseca SC, Oliveira PW, Brito AS. Fetal and infant
cross-sectional studies. BJOG. 2014;121:110-8. https://doi. mortality trends according to the avoidability of causes of death
org/10.1111/1471-0528.12637 and maternal education. Rev Bras Epidemiol. 2021;24. https://
doi.org/10.1590/1980-549720210008.supl.1
10. Silva AA, Leite AJ, Lamy ZC, Moreira ME, Gurgel RQ, Cunha
AJ, et al. Neonatal near miss in the Birth in Brazil survey. Cad 23. Fonseca SC, Flores PV, Camargo KR Jr, Pinheiro RS, Coeli CM.
Saude Publica. 2014;30:S1-10. https://doi.org/10.1590/0102- Maternal education and age: inequalities in neonatal death.
311x00129613 Rev Saude Publica. 2017;17:94. https://doi.org/10.11606/
s1518-8787.2017051007013
11. Kale PL, Mello-Jorge MH, Laurenti R, Fonseca SC, Silva KS.
Pragmatic criteria of the definition of neonatal near miss: a 24. Garcia LP, Fernandes CM, Traebert J. Risk factors for neonatal
comparative study. Rev Saude Publica. 2017;51:111. https:// death in the capital city with the lowest infant mortality
doi.org/10.11606/S1518-8787.2017051006587 rate in Brazil. J Pediatr (Rio J). 2019;95:194-200. https://doi.
org/10.1016/j.jped.2017.12.007
12. Noli SA, Baini I, Parazzini F, Mauri PA, Vignali M, Gerli S, et al.
Preterm birth, low gestational age, low birth weight, parity, 25. Lean SC, Derricott H, Jones RL, Heazell AEP. Advanced maternal
and other determinants of breech presentation: results from age and adverse pregnancy outcomes: a systematic review
a large retrospective population-based study. Biomed Res Int. and meta-analysis. PLoS One. 2017;12:e0186287. https://doi.
2019;2019:9581439. https://doi.org/10.1155/2019/9581439 org/10.1371/journal.pone.0186287

13. França KE, Vilela MB, Frias PG, Gaspar GS, Sarinho SW. Early 26. Mersha A, Bante A, Shibiru S. Factors associated with neonatal
neonatal near miss identified through health information near-miss in selected hospitals of Gamo and Gofa zones, southern
systems. Cad Saude Publica. 2018;34:e00167717. https://doi. Ethiopia: nested case-control study. BMC Pregnancy Childbirth.
org/10.1590/0102-311x00167717 2019;19:516. https://doi.org/10.1186/s12884-019-2684-x

14. Leal MC, Esteves-Pereira AP, Viellas EF, Domingues RM, Gama 27. Lansky S, Friche AA, Silva AA, Campos D, Bittencourt DA, Carvalho
ML, et al. Birth in Brazil survey: neonatal mortality, pregnancy
SG. Prenatal care in the Brazilian public health services. Rev
and childbirth quality of care. Cad Saude Publica. 2014;30:S192-
Saude Publica. 2020;54:8. https://doi.org/10.11606/s1518-
207. https://doi.org/10.1590/0102-311x00133213
8787.2020054001458
15. Santana DS, Souza RT, Surita FG, Argenton JL, Silva CM, Cecatti 28. Costa MF, Gomes Jr S, Magluta C. Analysis of the distribution
of births with severity markers in maternity with neonatal
JG. Twin pregnancy in Brazil: a profile analysis exploring
intensive care unit in the Unified Health System. Cad Saúde
population information from the national birth e-registry on
Colet. 2018;26:125-30. https://doi.org/10.1590/1414-
live births. Biomed Res Int. 2018;2018:9189648. https://doi.
462X201800020419
org/10.1155/2018/9189648
16. Pedreira CE, Pinto FA, Pereira SP, Costa ES. Birth weight patterns 29. Szwarcwald CL, Leal MD, Esteves-Pereira AP, Almeida WD,
Frias PG, Damacena GN, et al. Evaluation of data from the
by gestational age in Brazil. An Acad Bras Cienc. 2011;83:619-25.
Brazilian Information System on Live Births (SINASC). Cad Saude
https://doi.org/10.1590/s0001-37652011005000008
Publica. 2019;35:e00214918. https://doi.org/10.1590/0102-
17. Kiserud T, Benachi A, Hecher K, Perez RG, Carvalho J, Piaggio G, 311x00214918
et al. The World Health Organization fetal growth charts: concept,
30. Kale PL, Fonseca SC, Gama SG. Neonatal near miss and the
findings, interpretation, and application. Am J Obstet Gynecol.
occurrence of negative outcomes in the first year of life: data
2018;218:S619-29. https://doi.org/10.1016/j.ajog.2017.12.010
from a national survey, Nascer no Brasil (Born in Brazil), 2011-
18. Brazil - Ministério da Saúde. Como nascem os brasileiros: uma 2012. Rev Bras Saúde Mater Infant. 2020;20:789-98. https://
análise da adequação da assistência pré-natal e das indicações de doi.org/10.1590/1806-93042020000300007

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