A mortalidade neonatal, em sua maioria, ocorre por causas que poderiam ser evitadas se houvesse oferta de serviços qualificados durante o pré-natal, parto e puerpério. De modo geral, estão associadas às condições biológicas, às disparidades socioeconômicas e de acesso aos serviços de saúde. Assim, mesmo em municípios com melhores índices de desenvolvimento econômico, a elucidação dos elementos que compõem a trama de causalidade dos óbitos neonatais é fundamental. Dessa forma, o objetivo do estudo foi analisar os fatores associados aos óbitos neonatais no Município de Londrina-PR, no período de 2000 a 2009. Foram investigados os óbitos neonatais, segundo características maternas, do recém-nascido e relativas ao uso do sistema municipal de saúde, por meio de estudo retrospectivo descritivo do tipo ecológico. Os dados foram extraídos da Declaração de Nascido Vivo, da Declaração de Óbito e das Fichas de Investigação do Óbito Infantil do Comitê Municipal de Prevenção de Mortalidade Materno-Infantil do Núcleo de Informação de Mortalidade (NIM) da Secretaria de Saúde Municipal. No que se refere à caracterização materna, mais de 60,0% das mães eram jovens adultas (12 a 27 anos) e a média de idade 25,8 anos. Ao longo dos 10 anos, o número de mães adolescentes diminuiu de 22,9% para 8,5%. Do total, 83,5% tinham companheiro, 73,9% de oito a onze anos de estudo e 52,7% não trabalhavam. Tiveram acompanhamento no pré-natal 91,4% das mulheres, 55,1% das quais se consultaram de uma a seis vezes. Quase a totalidade apresentou algum tipo de afecção durante a gestação: 82,7% trabalho de parto prematuro e 36,7% doenças renais e de vias urinárias. Pouco mais de 51,0% evoluiu para o parto vaginal. Ao longo dos anos, o parto cirúrgico aumentou de 35,4% para 61,5%. Quanto às características dos recém-nascidos que foram a óbito, 56,9% eram do sexo masculino e 86,0% da raça branca. Aproximadamente 60,0% nasceram entre 22 e 31 semanas de gestação e 60,7% tinham peso inferior a 1.500 gramas e 73,0% apresentaram asfixia no 1º minuto de vida. Ao longo dos anos, a prematuridade se manteve elevada. A média de idade do óbito foi de 4,9 dias. A maioria das mortes ocorreu no período neonatal precoce (73,9%) e o Coeficiente de Mortalidade Neonatal passou de 21,2 para 14,8, entre 2000 e 2009. A causa básica foram, predominantemente, afecções perinatais (77,6%), seguidas das anomalias congênitas (20,0%). Do total das mortes evitáveis, 77,1% ocorreram por causas redutíveis por adequado controle na gravidez e atenção ao parto. Quanto ao uso do sistema municipal de saúde pelas mães dos neonatos observou-se que 62,3% realizaram o pré-natal no serviço público de saúde. A quase totalidade dos partos ocorreu no hospital (96,5%), sendo 63,7% em hospitais que ofereciam atendimento obstétrico e de unidade de terapia intensiva neonatal (UTIN). Ao longo dos 10 anos de estudo, o uso do serviço hospitalar com maternidade e UTIN, aumentou de 39,2% para 66,6%. O período do óbito neonatal apresentou associação estatisticamente significativa com: trabalho de parto prematuro (p<0,01), infecção do trato urinário (p<0,05), hipertensão arterial/pré-eclâmpsia (p<0,01), peso ao nascer (p<0,01), idade gestacional (p<0,01), Apgar no 1º e 5º minuto (p<0,01), local do parto (p<0,01) e local do óbito (p<0,05). Por outro lado, não houve associação estatística com as características demográficas e socioeconômicas maternas. Ainda que as mortes neonatais tenham sido reduzidas, ao longo dos anos, no Município de Londrina, a sua ocorrência requer atenção para a reorganização do sistema de saúde, particularmente no que se refere à qualificação da assistência pré-natal e parto. Conclui-se ser necessária a operacionalização da integralidade de forma a abordar as necessidades materno-infantis que recorrerem ao serviço municipal de saúde. / Neonatal mortality mostly occurs due to avoidable causes which could be prevented if quality health services were available at prenatal, delivery and postnatal periods. In general, these causes are related to biological conditions, socioeconomic disparities and health services accessibility. Hence, even in cities where the economic development is high, it is fundamental to elucidate factors that contribute to the causality of neonatal deaths. The aim of this study was to analyze the factors associated to neonatal deaths in Londrina - PR, from 2000 to 2009. Neonatal deaths were investigated according to characteristics of mothers, newborns and health system city services through an ecological study with a retrospective and descriptive approach. Data were obtained from Birth Certificates, Death Certificates and Infant Death Investigation Forms provided by the Municipal Committee for Prevention of Maternal and Infant Death obtained from the Mortality Information Center assigned under the City Health Department. Regarding maternal characteristics, more than 60.0% were young adults (aged from 12 to 27), mean age of 25.8. Over this ten-year period, the number of teenager mothers decreased from 22.9% to 8.5%. Out of the total, 83.5% were married, 73.9% had 8-11 schooling years and 52.7% did not have a job. Most women (91.4%) received prenatal care and 55.1% of them attended to 1-6 prenatal care appointments. Almost all mothers had some sort of health problems during pregnancy: 82.7% presented with premature labor and 36.7% had renal and urinary conditions. Slightly more than 51,0% led to natural deliveries. Over the years, surgical deliveries increased from 35.4% to 61.5%. As for characteristics of newborns who died, 56.9% were male and 86.0% were caucasian. About 60.0% were born with 22-31 weeks of gestational age and 60.7% weighted under 1500 grams and 73.0% presented with asfixiation at the first minute. Over the studied period, prematurity rates remained elevated. Mean death age was 4.9 days. Most deaths occured at early neonatal period (73.9%) and the Neonatal Mortality Rate decreased from 21.2 to 14.8 between 2000 to 2009. The leading death causes were perinatal conditions (77.6%) followed by congenital anomalies (20.0%). Out of all avoidable deaths, 77.1% occured due to causes that could be prevented if adequate control over pregnancy and labor care were available. As for the city health services attended by the newborns\' mothers, 62.3% used the public health system. Almost all labors took place in hospitals (96.5%), and 63.7% of these facilities provided obstetric and neonatal intensive care. In the studied period, the use of hospital facilities with maternity/nursery and neonatal intensive care wards increased from 39.2% to 66.6%. The neonatal death period was statistically associated to premature labor (p<0.01), urinary tract infeccion (p<0.05), arterial hypertension/pre-eclampsia (p<0.01), birth weight (p<0.01), gestational age (p<0.01), Apgar score at 1st and 5th minutes (p<0.01), place of delivery (p<0.01) and place of death (p<0.05). On the other hand, there was no statistical association between maternal demographic and socioeconomical characteristics. Even though neonatal deaths have decreased over the years, in Londrina, this number still requires attention in order to reorganize the health system, specifically regarding qualified assitance for prenatal care and delivery. In conclusion, it is necessary to implement integrative care as to address the maternal-infant needs of the population who attends the city health services.

O objetivo da tese é descrever uma coorte de nascidos vivos e os óbitos neonatais dela derivados e estimar as probabilidades de morte segundo características do recém-nascido, da gestação, do parto e da mãe, bem como das causas de morte. Utilizou-se como fonte de obtenção de dados as Declarações de Nascido Vivo (DN) e de Óbito (DO),documentos básicos dos Sistemas Oficiais de Informação do país. A coorte foi formada por 3225 nascimentos vivos de mães residentes e ocorridos no Munícipio de Santo André, no 1º semestre de 1992. Para a identificação dos óbitos neonatais foi empregada a técnica de \"linkage\", pareando-se as DO com as respectivas DN, obtendo-se 55 óbitos neonatais. A proporção de nascidos vivos de baixo peso ao nascer foi de 6,8 por cento . Obteve-se associação estatisticamente significativa para os nascidos vivos de baixo peso e a presença de gestações de pré-termo, parto normal e cujo nascimento havia ocorrido no hospital público do SUS. Este hospital é referência para as gestações de risco do municipio. Essa associação estava presente também nos recém-nascidos de mães adolescentes e idosas e nos de mães prímiparas ou grandes multíparas. Não se encontrou associação entre o baixo peso ao nascer e sexo, bem como com a variável anotação do nome do pai na DN. Os óbitos concentraram-se no 10 dia de vida (54,5 por cento ).Verificou-se que 94,6 por cento das crianças morreram sem que estas tivessem deixado o hospital após o nascimento. Com relação às causas básicas de morte, as mais frequentes foram as afecções perinatais. A análise das causas múltiplas permitiu uma melhor avaliação da participação da imaturidade/prematuridade e das infecções perinatais no processo que levou a morte. Estas causas estiveram presentes como causa básica ou associada em 63,6 por cento e 25,5 por cento dos óbitos, respectivamente. Os fatores de risco para os óbitos neonatais foram baixo peso ao nascer, gestações de pré-termo e a ausência do registro do nome do pai. Os partos cesareanos foram considerados como fator de confusão para o risco de morte neonatal, o efeito protetor destes partos desapareceu ao se controlar o peso ao nascer. O maior risco de morte encontrado nos nascimentos no hospital público do SUS também deixou de existir ao se controlar a variável peso. Observou-se um risco de morte significativamente maior para os nascidos vivos de baixo peso do sexo masculino que nos do sexo feminino. A categoria de recém-nascidos de baixo peso e de pré-termo apresentou risco de morte 82 vezes maior que os de termo com peso igual ou superior a 2500 gramas. Não se encontrou um risco de morte significativo para os nascidos vivos de mães primíparas ou grandes multíparas e de mães adolescentes ou idosas em relação aos recém-nascidos de mães multíparas e com idade entre 20 e 34 anos. Foram considerados como nascidos vivos de risco os nascimentos de baixo peso. Observou-se um risco de morte significativamente maior por anomalias congênitas e afecções perinatais nos nascimentos de baixo peso que entre aqueles que tinham peso igual ou acima de 2500 gramas. O risco de morte por infecções perinatais foi 94,0 vezes maior nesse grupo de recém-nascidos. Os nascidos vivos de baixo peso do sexo masculino apresentaram uma chance 3,6 vezes mais elevada de morrer por afecções respiratórias que os do sexo feminino deste grupo. Os dados obtidos sugerem que muitos destes óbitos poderiam ter sido evitados se houvesse uma melhor identificação das gestações de risco no pré-natal e fosse assegurada uma adequada atenção ao parto e aos recém-nascidos, bem como indicam que nem todos recém-nascidos de risco receberam os cuidados nescessários após o parto. / A cohort of live births was analysed and the risk of death according to some variables was estimated. The data was obtained from the birth and death certificates. The records were linked, and each death was matched with the birth certificate, in order to identify the neonatal deaths and the survivals of the cohort. It was studied 3,225 live borns of resident mothers of the Santo André Municipality. The births occurred in this area from 01/101/1992 to 06/30/1992. The incidence of low birthweight was 6.8 per cent and the proportion of preterm infants was 5.3 per cent . The low birthweight was associated to the preterm gestation, vaginal deliveries, and to the births which occurred on the SUS public hospital. There was also an association between the low birthweight and the live borns from adolescent and older mothers. The low and high parity were risk factors to the low birthweight. The abscence of notation of the father\'s name on the birth certificate was not associated to the low birthweight. The deaths occurred mainly in the first day of the life (54.5 per cent ) . The data showed that 94.6 per cent of the infant deaths occurred before hospital discharge . The perinatal afections were the leading cause of death. The prematurity/imaturity was assigned as underlying or associated cause in 63.6 per cent of the deaths and the perinatal infections in 25.5 per cent of these deaths. It was found a higher risk of death in low birthweight and preterm newborns and in infants with abscence of the father\'s name on the birth certificate. The cesarean section deliveries showed to be a confounding factor to the neonatal deaths, as well as, the type of the hospital in which the infants were deliveried. The male low birthweight infants presented higher risk of death than the female infants. The low birthweight and preterm babies showed a 82 times higher risk of dying than the normal weight and term infants. The low birthweight newborn showed a higher risk of death from congenital anommalies and perinatal afections. This group of live births, also presented a risk of death from perinatal infections 94.0 times higher than the normal weight babies. The male low birthweigth infants presented 3.6 times higher chance of dying from perinatal respiratory afections than the female newborns of this group. These results suggest that some deaths could be avoided by adequate prenatal, delivery and neonatal care in the maternity wards. The high risk death found in the preterm and very low birth weight infants also suggest that some of these high risk newborns did not had access to neonatal intensive care.

Introdução: O presente estudo trata da evolução da mortalidade perinatal hospitalar do município de Fortaleza-Ceará em dois momentos: 1995 e 2005. O interesse para a realização desta pesquisa parte da relevância dos cuidados oferecidos à mulher grávida e ao recém nascidocomo importante indicador da saúde materno infantil.Objetivos: Avaliar a evolução dos indicadores de saúde perinatal referentes aos nascimentos hospitalares de Fortaleza, Ceará, ocorridos em 1995 e em 2005.Metodologia: Estudo epidemiológico, do tipo ecológico, que estuda a evolução da saúde perinatal em Fortaleza, de 1995 a 2005, a partir da análise dos dados de dois estudos de base hospitalar. Todos os nascimentos foram acompanhados desde o parto até a alta ou óbito em hospital.Fizeram parte da população, todos os nascimentos e respectivos óbitos perinatais ocorridos em hospitais/maternidades públicas e particulares, conveniados com o SUS, no município de Fortaleza, CE, em 1995 e em 2005, disponíveis em dois bancos de dados já existentes.Resultados: Os resultados evidenciaram que nos dez anos (1995-2005) houve melhoria nos indicadores de saúde perinatal em Fortaleza. Os coeficientes de mortalidade perinatal hospitalar, fetal e neonatal precoce tiveram redução de 29 por cento, 19,0 por cento e de 42 por cento respectivamente. Em crianças com baixo peso ao nascer,observou-se declínio na mortalidade perinatal, fetal e neonatal precoce em todas as categorias. Chama-se atenção para a redução do coeficiente de mortalidade perinatal no grupo de recém nascidos de muito baixo peso (< 1500g), que passou de 821,1/1000 NV em 1995 para 532,2/1000 NV em 2005, com um declínio de 35,2 por cento. Quanto ao coeficiente de mortalidade neonatal precoce, a redução foi de 53,8 por cento, passando de 703,0/1000 NV para 324,7/1000 NV. Foi possível evidenciar mudanças referentes à reorganização da atenção perinatal em Fortaleza, quando se detectou uma maior participação dos hospitais públicos, que realizou um maior número de partos nos dez anos em 121 por cento por cento. Em 1995 a proporção de partos foi de 32,4 por cento e em 2005 de 71,7 por cento. Quanto à idade materna, os coeficientes de mortalidade perinatal, fetal e neonatal precoce nos dez anos tiveram reduções, com ênfase entre os filhos de mães adolescentes (10 a 19 anos). Para este grupo, o coeficiente de mortalidade perinatal obteve declínio de 54,2 por cento o de mortalidade fetal de 16,2 por cento e o de mortalidade neonatal precoce de 36,8 por cento. Conclusões: A mudança nos indicadores da saúde perinatal no município de Fortaleza mostra que houve uma melhora da atenção ao longo dos dez anos, revelando um cenário favorável na atenção prestada à mulher grávida e ao recém nascido na capital. Contudo, sabe-se que aspectos relacionados com o processo de trabalho e a organização da rede, ainda permanecem em níveis inferiores em relação , quando compara-se com outras capitais brasileiras, sendo necessárias medidas governamentais para que estas lacunas sejam remediadas / Introduction: This study deals with the evolution of perinatal mortality hospital in Fortaleza, Ceara on two occasions: 1995 and 2005. The interest for this research part of the relevance of care offered to pregnant women and newborn care as an important indicator of maternal and infant health.Objectives: To evaluate perinatal health indicators relating to hospital births in Fortaleza, occurring in 1995 and 2005.Methodology: Epidemiological study of ecological type, which studies the evolution of perinatal health in Fortaleza, from 1995 to 2005, based on the analysis of data from two hospital-based studies. All births were followed from birth until discharge or death in hospital. The population was composed of all births and perinatal deaths occurred in their hospitals / public hospitals and private contracts with the SUS in the city of Fortaleza, in1995 and 2005, available in two databases that already exist.Results: The results showed that within ten years (1995-2005) found a reduction in perinatal health indicators in Fortaleza. The hospital perinatal mortality rates, fetal and early neonatal fell by 29 per cent, 19.0 per cent and 42 per cent respectively. As birth weight were obtained decline in perinatal mortality, fetal and early neonatal in all categories. Attention is drawn to the reduction of perinatal mortality rate in the group of infants with very low birthweight (<1500g), now 821.1 / NV in 1000 to 532.2 in 1995 / 1000 NV in 2005, with a declining 35.2 per cent. As for early neonatal mortality rate, the reduction was 53.8 per cent, from 703.0 / 324.7 for 1000 NV / NV 1000. The results showed changes related to the reorganization of perinatal care in Fortaleza, when it detected a greater involvement of public hospitals, which increased the number of births in the ten years 121 per cent per cent. In 1995 the proportion of births was 32.4 per cent and 71.7 per cent in 2005. As for maternal age, perinatal mortality rates, fetal and early neonatal ten years have had reductions, with emphasis among the children of teenage mothers (10-19 years). For this group, the perinatal mortality rate decline of 84.7 per cent was obtained, the fetal mortality of 46.8 per cent and early neonatal mortality rate of 88.7 per cent.Conclusions: The change in perinatal health indicators in Fortaleza shows that there was an improvement of attention over the ten years, revealing a favorable outlook on care provided to pregnant women and newborn in capital.Contudo, it is known that aspects related to the work process and organization of the network, are still inconsistent when it is compared with other Brazilian cities, requiring government measures to these deficiencies are remedied

Magister Public Health - MPH / Background: Globally, neonatal mortality (i.e. deaths occurring during the first month of life) accounts for 44% of the 11 million infants that die every year (Lawn, Cousens Zupan, 2005). Early detection of illness and referral of mothers and infants during the peri-natal period to higher levels of care can lead to substantial reductions in maternal and child mortality in developing countries. Establishing effective referral systems from the community to health facilities can be achieved through greater utilization of community health workers and improved health seeking behaviour. Study design: The Good Start Saving Newborn Lives study being conducted in Umlazi, KwaZulu-Natal, is a community randomized trial to assess the effect of an integrated home visit package delivered to mothers during pregnancy and post delivery on uptake of PMTCT interventions and appropriate newborn care practices. The home visit package is delivered by community health workers in fifteen intervention clusters. Control clusters receive routine health facility antenatal and postpartum care. For any identified danger signs during a home visit, community health workers write a referral and if necessary refer infants to a local clinic or hospital. The aim of this study was to assess the effectiveness of this referral system by describing community health worker referral completion rates as well as health-care seeking practices and perceptions of mothers. A cross- sectional survey was undertaken using a structured questionnaire with all mothers who had been referred to a clinic or hospital by a community health worker since the start of the Good Start Saving Newborn Lives Trial. Data collection: Informed consent was obtained from willing participants. Interviews were conducted by a trained research assistant in the mothers home or at the study offices. Road to Health Cards were reviewed to confirm referral completion. Data was collected by means of a cell phone (mobile researcher software) and the database was later transferred to Epi-info and STATA IC 11 for analysis. Descriptive analysis was conducted so as to establish associations between explanatory factors and referral completion and to describe referral processes experienced by caregivers. Significant associations between categorical variables were assessed using chi square tests and continuous variables using analysis of variance. Results: A total of 2423 women were enrolled in the SNL study and 148 had received a referral for a sick infant by a CHW by June 2010. The majority (95%) of infants were referred only once during the time of enrolment, the highest number of which occurred within the first 4 weeks of life (62%) with 22% of these being between birth and 2 weeks of age. Almost all mothers (95%) completed the referral by taking their child to a health facility. Difficulty in breathing and rash accounted for the highest number of referrals (26% and 19% respectively). None of the six mothers who did not complete referral recognised any danger signs in their infants. In only 16% of cases did a health worker give written feedback on the outcome of the referral to the referring CHW. Conclusion: This study found high compliance with referrals for sick infants by community health workers in Umlazi. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health (SANDOH) which will involve the establishment of family health worker teams including community health workers. A key function of these workers will be to conduct antenatal and postnatal visits to women in their homes and to identify and refer ill children. Failure of mothers to identify danger signs in the infant was associated with non-completion of referral. This highlights the need for thorough counseling of mothers during the antenatal and early postnatal period on neonatal danger signs which can be reinforced by community health workers. Most of the referrals in this study were neonates which strengthens the need for home visit packages delivered by community health workers during the antenatal and post-natal period as currently planned by the South African National Department of Health.Recommendations: This study supports the current plans of the Department of Health for greater involvement of CHWs in Primary Health Care. Attention should be given to improving communication between health facilities and CHWs to ensure continuity of care and greater realization of a team approach to PHC. / South Africa

The aim of this thesis was to analyse detailed data on the development of infant mortality for different countries and their comparison. The countries were selected from several parts of Europe to provide high quality data for analysis. Different components of infant mortality with respect to data availability were examined as well as infant mortality by gender. Comparisons among selected countries were made based on different variability measures. Largely, the thesis deals with infant mortality depending on the level of development of the countries. Using regression and correlation analysis, infant mortality dependence was determined on various determinants with prerequisites to explain part of the infant mortality variability. The selected determinants include, for example, GDP per capita, unemployment rate or life expectancy.

Depuis plusieurs années, des projets d'intégration de données omiques se sont développés, notamment avec objectif de participer à la description fine de caractères complexes d'intérêt socio-économique. Dans ce contexte, l'objectif de cette thèse est de combiner différentes données omiques hétérogènes afin de mieux décrire et comprendre le dernier tiers de gestation chez le porc, période influençant la mortinatalité porcine. Durant cette thèse, nous avons identifié les bases moléculaires et cellulaires sous-jacentes de la fin de gestation, en particulier au niveau du muscle squelettique. Ce tissu est en effet déterminant à la naissance car impliqué dans l'efficacité de plusieurs fonctions physiologiques comme la thermorégulation et la capacité à se déplacer. Au niveau du plan expérimental, les tissus analysés proviennent de foetus prélevés à 90 et 110 jours de gestation (naissance à 114 jours), issus de deux lignées extrêmes pour la mortalité à la naissance, Large White et Meishan, et des deux croisements réciproques. Au travers l'application de plusieurs études statistiques et computationnelles (analyses multidimensionnelles, inférence de réseaux, clustering et intégration de données), nous avons montré l'existence de mécanismes biologiques régulant la maturité musculaire chez les porcelets, mais également chez d'autres espèces d'intérêt agronomique (bovin et mouton). Quelques gènes et protéines ont été identifiées comme étant fortement liées à la mise en place du métabolisme énergétique musculaire durant le dernier tiers de gestation. Les porcelets ayant une immaturité du métabolisme musculaire seraient sujets à un plus fort risque de mortalité à la naissance. Un second volet de cette thèse concerne l'imputation de données manquantes (tout un groupe de variables pour un individu) dans les méthodes d'analyses multidimensionnelles, comme l'analyse factorielle multiple (AFM) (ou multiple factor analysis (MFA)). Dans notre contexte, l'AFM fut particulièrement intéressante pour l'intégration de données d'un ensemble d'individus sur différents tissus (deux ou plus). Afin de conserver ces individus manquants pour tout un groupe de variables, nous avons développé une méthode, appelée MI-MFA (multiple imputation - MFA), permettant l'estimation des composantes de l'AFM pour ces individus manquants. / Over the last decades, some omics data integration studies have been developed to participate in the detailed description of complex traits with socio-economic interests. In this context, the aim of the thesis is to combine different heterogeneous omics data to better describe and understand the last third of gestation in pigs, period influencing the piglet mortality at birth. In the thesis, we better defined the molecular and cellular basis underlying the end of gestation, with a focus on the skeletal muscle. This tissue is specially involved in the efficiency of several physiological functions, such as thermoregulation and motor functions. According to the experimental design, tissues were collected at two days of gestation (90 or 110 days of gestation) from four fetal genotypes. These genotypes consisted in two extreme breeds for mortality at birth (Meishan and Large White) and two reciprocal crosses. Through statistical and computational analyses (descriptive analyses, network inference, clustering and biological data integration), we highlighted some biological mechanisms regulating the maturation process in pigs, but also in other livestock species (cattle and sheep). Some genes and proteins were identified as being highly involved in the muscle energy metabolism. Piglets with a muscular metabolism immaturity would be associated with a higher risk of mortality at birth. A second aspect of the thesis was the imputation of missing individual row values in the multidimensional statistical method framework, such as the multiple factor analysis (MFA). In our context, MFA was particularly interesting in integrating data coming from the same individuals on different tissues (two or more). To avoid missing individual row values, we developed a method, called MI-MFA (multiple imputation - MFA), allowing the estimation of the MFA components for these missing individuals.

Objetivo: Avaliar o impacto do nascimento pré-termo sobre a mortalidade neonatal numa série temporal de 2000 a 2014 no município de Porto Alegre. Métodos: Estudo de coorte retrospectivo de base populacional com a utilização dos registros oficiais de nascimento e de morte ligados de 2000 a 2014 de recém-nascidos com menos de 32 semanas de idade gestacional de Porto Alegre. Foram utilizadas como variáveis independentes idade e escolaridade maternas, número de consultas pré-natal, tipo de hospital, via de parto, idade gestacional (IG), sexo e peso do recém-nascido e ano de nascimento. O desfecho primário foi morte neonatal (morte ocorrida de 0 a 27 dias de vida). Foram excluídos recém-nascidos duplicados, com menos de 500 gramas ou com peso inconsistente, com IG menor de 22 semanas, com anomalias congênitas, gemelares e de partos extra hospitalares. Foi calculado razão de risco (hazard ratio-HR) ajustado para o risco de morte neonatal para todas as variáveis independentes através de análise de sobrevivência pela regressão de Cox para riscos proporcionais com nível de significância p<0,05. Posteriormente, foi realizado análise por quintil de peso de nascimento. Resultados: Foram analisados os registros de 3282 recém-nascidos com IG menor que 32 semanas de 2000 a 2014 dos quais, 643 foram ao óbito neonatal e 2639 sobreviveram. O risco de morte neonatal absoluto diminuiu de 25% no triênio 2000 a 2002 para 17% no período de 2012 a 2014. O mesmo risco ajustado foi significativamente menor para os recém-nascidos de menor peso (média de 673 ± 86 gramas) de parto cesáreo [HR 0,57 (IC95% 0,45-0,73)] enquanto que, para os de maior peso (média 1.834 ± 212 gramas) este risco inverteu-se e foi significativamente maior para esta via de parto [HR 8,44 (IC95% 1,86-38,22)]. Conclusão: Houve diminuição do risco absoluto de morte neonatal entre os recém-nascidos com IG menor de 32 semanas nos últimos anos em Porto Alegre e o aprimoramento do uso racional do parto cesáreo nos hospitais do município pode contribuir para uma redução ainda maior desse indicador. / Objective: Assess impact of prematurity on neonatal mortality from 2000 to 2014 in Porto Alegre through official information systems. Methods: Populational base retrospective cohort study with record linkage of birth and death database certificates. There were included records of birth and death from 2000 to 2014 of infants with less than 32 weeks of gestational age of Porto Alegre. There were used mother age and schooling, number of antenatal visits, delivery type, hospital type, gestational age, sex and birth weight and birth year of infant as independent variables. The primary outcome examined was neonatal death (death at 0-27 days of age). There were excluded infant records duplicate, with less than 500g or inconsistent birthweight, with gestational age less than 22 weeks, with congenital anomalies, twins and out-of-hospital births. Adjusted Hazard Ratio (HR) were calculated for the risk of neonatal death for all independent variables through Cox regression for survival analysis with p-value<0,05 for statistical significance. The analysis also was performed at quintiles of birthweight. Results: There were 3282 infant records of infants with less than 32 weeks of gestational age from 2000 to 2014 who progress to 643 neonatal deaths or 2639 survival. The neonatal death absolut risk decline from 25% at 2000-2002 period to 17% at 2012-2014 period. The adjusted neonatal death risk was significantly reduced for lightest preterm (mean birthweight 673g ± 86) born by C-section [HR 0.57 (CI95% 0.45-0.73)], while, for the heaviest ones (mean birthweight 1.834g ± 212) the risk was significantly increased for that delivery route [HR 8.44 (CI95% 1.86-38.22)]. Conclusion: The absolut risk of neonatal death in infants with less than 32 weeks of gestational age has been declining over the years and more rational use of C-section can contribute to further improving the neonatal survival.

Thesis (M.Med. (Paediatrics and Child Health)) -- University of Limpopo, 2019 / Objectives To determine the prevalence and survival rate; and to assess the maternal risk factors as well as complications of prematurity, associated with the mortality of very low and extremely low birth weight infants in the Neonatal Intensive Care Unit (NICU) of Mankweng Hospital. Materials and Methods A retrospective descriptive study was conducted at the NICU of Mankweng Hospital for a 7-month period from 1st January to 31st July 2015. The patient medical records and the Perinatal Problem Identification Programme (PPIP) data were used for the study. Results Prevalence of prematurity was 23%, Infants weighing between 500g-1499g represented 6.3% of the total live births and 25% of the admissions to the NICU; of which 4.9% were classified as extremely low birth weight (ELBW). Overall 77% of the study population survived until discharge. From the medical records, the survival to discharge of infants with weight 500g - 999g was 52%; and 84% for those with weight 1000g-1499g. Multivariable analysis found that improved survival was associated with an increase in gestational age (p <0.001), as well as birth weight (p <0.001) and prolonged length of stay. Variables associated with poor survival were spontaneous preterm labour (p = 0.031), low Apgar score at 1 and 5 minutes (p <0.001), sepsis (p = 0.001), respiratory distress syndrome (p <0.001), pulmonary hemorrhage (p <0.001), hypothermia (P = 0.005), resuscitation at birth (p = 0.002) and necrotising enterocolitis (p =0.044). Antenatal steroids were not associated with survival (p =0.111), however this was not documented in 53%(134/252) of the records, so the non-significance to outcome in this study may not be a true reflection. The use of NCPAP or SiPAP only was associated with improved survival of up to 69% and high mortality rates were recorded in babies who required invasive ventilator support. Multi-organ immaturity was found to be the most common cause of death, followed by sepsis. Conclusion: The prevalence and survival rates of very low and extremely low birth weight, found in this study are comparable to those found in other tertiary hospitals in South Africa. The survival rate of ELBW babies is low and must be improved. Reliable data and further research should address effective steps to prevent preterm labour, extreme prematurity and hypothermia. The documentation and provision of antenatal steroids is encouraged. KEY CONCEPTS: Prematurity, Extremely low and Very low birth weight, Risk factors, Prevalence, Survival, Neonatal mortality rate.

This doctoral thesis is devoted to the study of the effects of late fertility on health of the newborn and to the implications of late fertility in the fertility decision process. Late fertility is defined as the reproduction process after 30 years old. The interest lies as well from the maternal age point of view as from the paternal age point of view. The first part is devoted to the study of the determinants of infant morbidity and mortality with a particular attention to the parental age, without neglecting the other determinants. The originality of this part is located from the methodological point of view. We construct a structural model of infant morbidity/mortality in order to isolate the causal effect of late fertility. By a structural model we mean a model which represents a set of causal relationships represented mathematically by a multi-equation model and graphically by directed acyclic graphs. As a complementary approach, a chapter of the thesis is devoted to an exploratory model highlighting the role of the extreme values rather than average values traditionally of interest in most statistical analyses. Both methods are tested with Hungarian data: individual registration forms of livebirths and infant deaths (1984-1984 and 1994-1998), and the Hungarian case-control surveillance of congenital abnormalities (1997-2002). The second part analyses the effect of parental ageing in the fertility decision process. We try to determine whether the detrimental effect of late fertility on health of the child and on fecundity of the couples intervene in the preferences for a child. We assume that parental age influences the preferences for a child through effects on the desire for a child and on the beliefs in the capacity of reproduction of a healthy child. This hypothesis is tested using the data from the National Survey of Family Growth (United States, 2002) and from the Fertility and Family Survey (Hungary, Czech Republic and Belgium).

United Nations has lately stated ambitious health targets for 2030 in the Sustainable Development Goal agenda, following the already achieved progress between 1990 and 2015 when the number of children dying before the age of five was reduced by more than half. However, the mortality reduction in the first month of life after birth has not kept the same pace. Furthermore, a large number of stillbirths have previously not been accounted for. The aim of this thesis was to evaluate the impact of clinical training in neonatal resuscitation, and to identify strategies for an effective implementation at a maternal health facility in Nepal. Focus group discussions were used to explore the perceptions of teamwork among staff working closest to the infant at the facility. A prospective cohort study with nested referents was applied to determine effect on birth outcomes after an intervention with Helping Babies Breathe, a simplified protocol for neonatal resuscitation. Sustainability of the acquired skills after training was addressed by employing a quality improvement cycle. Video recordings of health workers performance were collected to analyse adherence to protocol. Midwives described the need for universal protocols in neonatal resuscitation and management involvement in clinical audit and feedback. There was a reduction of intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and neonatal mortality within 24 hours of life (aOR 0.51, 95% CI 0.31–0.83) after the intervention. Ventilation of infants increased (OR 2.56, 95% CI 1.67–3.93) and potentially harmful suctioning was reduced (OR 0.13, 95% CI 0.09–0.17). Neonatal death from intrapartum-related complications was reduced and preterm infants survived additional days in the neonatal period after the intervention. Low birth weight was not found to be a predictor of deferred resuscitation in the studied context. This study confirmed the robustness of Helping Babies Breathe as an educational tool for training in neonatal resuscitation. Accompanied with a quality improvement cycle it reduced intrapartum stillbirth and mortality on the day of delivery in a low-income facility setting. Improved postnatal care is needed to maintain the gains in survival through the neonatal period. Increased management involvement in audit and quality of care could improve clinical performance among health workers.