Abstract
The study sought to identify individual and contextual risk factors in healthcare and their interactions and regional differences in the determination of infant mortality in Brazilian state capitals. This was a case-control study that analyzed 7,470 infant deaths in 2012 in the 27 state capitals, recorded in the Brazilian Mortality Information System (SIM) and matched with the Brazilian Information System on Live Births (SINASC) through linkage and 24,285 controls obtained by sampling the surviving liveborn infants from 2011 to 2012 from the total of 1,424,691 births. The individual explanatory variables corresponded to information available in the SINASC database, and the contextual variable consisted of a quality index for hospital care in the 702 healthcare services where the births occurred. A multilevel logistic model was used to analyze interaction. The principal determinants of infant mortality were biological factors (low birthweight, prematurity, congenital malformations, severe/moderate asphyxia, and race/color), mediated by maternal socioeconomic factors (schooling, marital status, and occupation) and insufficiency of prenatal care. Low number of prenatal visits was a risk factor for infant mortality, independently of the service's quality, except in the state capitals in the South of Brazil. In the interaction between income and prenatal care, few prenatal visits and birth in high-income state capitals showed a higher risk when compared to births in low-income state capitals (OR = 0.68). Multilevel analysis evidenced regional inequalities in the risk models and reiterated the importance of biological determinants in the mediation of socioeconomic and healthcare factors in infant mortality.
Highlights
The individual explanatory variables corresponded to information available in the Sistema de Informações de Nascidos Vivos (SINASC) database, and the contextual variable consisted of a quality index for hospital care in the 702 healthcare services where the births occurred
In the interaction between income and prenatal care, few prenatal visits and birth in highincome state capitals showed a higher risk when compared to births in low-income state capitals (OR = 0.68)
Se por um lado os fatores biológicos apresentaram certa homogeneidade na composição dos modelos finais de risco para a mortalidade infantil, por outro é possível identificar maior relevância das características maternas como expressão das condições socioeconômicas das gestantes e dos recém-nascidos, nas regiões Norte, Nordeste e Sudeste, quando comparadas ao centro-sul do país
Summary
Após o linkage sucedeu-se a verificação do estabelecimento de nascimento da criança com base no código do Cadastro Nacional de Estabelecimentos de Saúde (CNES) registrado no SINASC (CODESTAB). No agregado das capitais constatou-se um maior número de mães dos sobreviventes que realizaram mais de sete consultas (61,1%), já nos casos foram 31,3% (Tabela 1). A Tabela 2 apresenta os valores da OR bruta e dos respectivos valores da significância estatística resultantes da análise bivariada entre o óbito infantil e as variáveis independentes do estudo, para o conjunto das capitais brasileiras e seus agregados nas respectivas macrorregiões. Na análise univariada entre o óbito infantil e as variáveis independentes não foram observadas associações significativas apenas para: estado civil nas regiões Sul e Centro-oeste; escolaridade, ocupação e número de filhos mortos no Centro-oeste; e tipo de parto nas capitais do Sul. As demais variáveis, portanto, foram incluídas no modelo multinível (Tabela 2)
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