Globally neonatal mortality accounts for 40% of under-five deaths. Participatory interventions where the local problems are addressed have been successful in some settings. The aim of this thesis was to describe challenges in perinatal health in a Vietnamese province, and to evaluate the effect of a facilitated intervention with local stakeholder groups that used a problem-solving approach to neonatal survival during three years. The NeoKIP trial (Neonatal Knowledge Into Practice, ISRCTN44599712) had a cluster-randomized design (44 intervention communes, 46 control). Laywomen facilitated Maternal-and-Newborn Health Groups (MNHGs) and used Plan-Do-Study-Act cycles to address perinatal health problems. Births and neonatal deaths were monitored. Interviews were performed in households of neonatal deaths and randomly selected live births. Use of health services was mapped. The primary healthcare staff’s knowledge on newborn care was assessed before and after the intervention. Neonatal mortality rate (NMR) was 16/1000 live births (variation 10 - 44/1000 between districts). Home deliveries accounted for one fifth of neonatal deaths, and health facilities with least deliveries had higher NMR. Main causes of death were prematurity/low birth-weight (37.8 %), intrapartum-related deaths (33.2 %) and infections (13.0 %). Annual NMR was 19.1, 19.0 and 11.6/1000 live births in intervention communes (18.0, 15.9 and 21.1 in control communes); adjusted OR 1.08 [0.66-1.77], 1.23 [0.75-2.01], and 0.51 [0.30-0.89], respectively. Women in intervention communes more frequently attended antenatal care, prepared for delivery and gave birth at institutions. Primary healthcare staff’s knowledge on newborn care increased slightly in intervention communes. This model of facilitation of local stakeholder groups using a perinatal problem-solving approach was successful and may be feasible to scale-up in other settings. / NeoKIP project in Vietnam

The neonate is still at risk of acquiring Group B Streptococcus (GBS) infection upon delivery even with the implementation of early onset GBS neonatal disease preventative protocols. GBS was reported as the most prevalent organism causing neonatal morbidity and mortality in the USA and Australia in the 1990s. GBS is also known to cause disease in children, women, the immunocompromised adult and the elderly, but it is the preterm neonates who are at greatest risk of GBS neonatal disease. The aim of this study was to determine the prevalence of lower genital tract (LGT) colonisation with GBS in Brisbane women of child bearing age. We also aimed: (i) to compare the GBS LGT prevalence rate of Indigenous and non Indigenous women; (ii) to determine whether previously reported risk factors for LGT colonisation with GBS were also risk factors associated with GBS colonisation of women in this study; (iii) to further develop and optimise a rapid PCR assay that could detect maternal LGT GBS colonisation; and (iv) to serotype the GBS strains that were isolated from pregnant and non pregnant women who participated in this study. This study recruited 374 women of childbearing age attending public medical providers and found an overall GBS prevalence of 98/374 (26.2%) for these Brisbane women, a rate higher than previously reported in Australia. When the GBS prevalence for pregnant women (25.6%) was compared to non pregnant women (27.2%) they were similar. We also compared the GBS LGT colonisation rate of women attending different medical providers. The GBS LGT prevalence rate for pregnant women attending the Mater was 36/118 (30.5%), whilst those women attending the Redlands Hospital antenatal clinic had a LGT GBS prevalence rate of only 7/53 (13.2%). By comparison, the LGT GBS prevalence rate for non pregnant women attending Biala Sexual Health clinic was 21/69 (30.4%) and 34/127 (26.8%) of women attending the Brisbane Family Planning Queensland were also GBS positive. The seven women recruited from Inala community centre tested negative for GBS LGT colonisation. The LGT GBS prevalence of Australian Aboriginal women was 5/22 (22.7%), a rate which was not significantly different from non-Aboriginal women 78/288 (27.1%). Established early onset GBS neonatal disease preventative policies have been recently revised. The CDC now recommends that all pregnant women are screened for LGT GBS colonisation during late gestation, and that any GBS isolates be tested for resistance to antibiotics if the GBS positive women have an allergy to penicillin. Queensland's Department of Health recommend that Queensland medical agencies implement a non screening based preventative protocol, where clinicians monitor: women prior to labour for reported risk factors associated with maternal GBS colonisation: women in labour for 'obstetric risk factors'. A number of risk factors have previously been reported in association with GBS LGT colonisation. However, in this current study we found that only one risk factor was significantly associated with current GBS: previous reported LGT GBS colonisation was significantly associated with maternal LGT GBS colonisation reported in this study. Women who previously tested positive for GBS were significantly more likely to be GBS positive in subsequent tests (OR 4.7; 95%CI, 1.8-12.5) compared to women with no previous history of GBS colonisation. An assessment of adverse pregnancy outcomes, preterm deliveries, and GBS colonisation data was made. It was established that 30 women had previously given birth to one or more preterm neonates and of these 30 women, nine (30%) of them tested positive for GBS in this current study. Of the 71 women who had given birth to neonates and who had suffered an adverse pregnancy outcome 25.3% also tested positive for GBS in this current study. GBS was identified in up to 30% of all mothers who had delivered their neonate preterm, 27.4% of women who had previously suffered miscarriages and 16.7% of women who had previously had stillbirths. In this study we found that Australian Aboriginal women also had a greater risk of delivering neonates who suffered from an adverse pregnancy outcome in comparison to all other women. Twenty one of the 22 Aboriginal women had previously been pregnant at least once, and nine (42.9%) of these women had at least one prior adverse pregnancy outcome while seven (33.3%) of these women had previously delivered at least one neonate preterm. Of the 21 Aboriginal women who had a previous pregnancy more than half the total number of Aboriginal women (11/21) had either delivered one or more neonates preterm or had suffered from one or more adverse pregnancy outcomes. When the incidence of adverse pregnancy outcomes was compared for Aboriginal and all other women the results were surprising. Overall, this study found 216 women including Aboriginal women had previously been pregnant and of these women 71 (32.8%) of them suffered an adverse pregnancy outcome. By comparison, only 62 of 195 (31.8%) non Aboriginal women but nine out of 21 (41.9%) Australian Aboriginal women suffered from a previous adverse pregnancy outcome. The clinical LGT GBS isolates found in this study of Brisbane women were typed and all nine GBS serotypes plus non typeable GBS serotypes were detected. Seventy women tested GBS culture positive and vaginal and/or perianal samples obtained from these women were evaluated. GBS serotype III was the serotype most frequently isolated from this total population, from 47.4% of pregnant women and 51.7% of non pregnant women. From some women only a single GBS serotype was isolated: in these women we found that GBS serotype III (50%) was the predominant isolate, followed by GBS serotype Ia isolated from 16.7% women. In addition 4.2% of women were colonised with GBS serotypes; Ib, II and V, whilst GBS serotypes IV and VII were isolated from 2.1% women. Non typeable GBS strains confirmed by latex agglutination tests accounted for 11.9% of all strains isolated from these Brisbane women. This study identified multiple serovars in 15 clinical samples and found that 22 (31.4%) women were colonised with mixed GBS serotypes in samples collected from both vaginal and perianal regions. In five women the combination of serotypes III/Ia were identified and in other women combinations of serotypes III/II, III/IV, III/V, III/VIII, Ia/IV and Ib/NT were also detected. In two instances three serotype combinations were detected in samples from one woman and these included serotypes III/Ib/II and III/Ia/Ib. Isolates were also typed for women who were colonised in both vaginal and perianal regions and it was found that only 10 participants had identical isolates in both regions. GBS serotype III was the predominant serotype detected in women tested in this study and this is the serotype that has previously been associated with invasive infections in neonates. GBS neonatal disease is a world wide economic, health and social burden affecting different ethnic groups and is preventable. Currently no vaccine technology is available for the prevention of GBS neonatal disease and the most effective EOGND preventative protocol would be to test for maternal GBS colonisation during labour, or screen women for GBS at &gt36 weeks' gestation and administer intrapartum antibiotic prophylaxis (IAP) to all women who tested positive for GBS. In this current study we utilised a rapid bsp PCR assay to detect LGT GBS colonisation in women of child bearing age. The PCR assay identified 62.5% of all vaginal and perianal positive culture GBS samples. The specificity of the PCR assay was 89% while the positive and negative predictive values were 56.8% and 91.1% respectively. This PCR assay using the current parameters is not an effective GBS detection assay but could be further optimised in the near future. This PCR assay could be an effective test in the future with the development of an alternative DNA extraction method to InstaGene (BioRad). However, this PCR assay if used in conjunction with the current culture method is able to detect a further 8.9% of women colonised with asymptomatic GBS. Brisbane women aged between 26 to 35 years who are pregnant and who are attending public health care agencies are at greatest risk of being colonised with GBS. No disparity was identified when ethnicity or social standing were assessed. The overall results of this study demonstrate that the LGT GBS prevalence rate in Brisbane women is 26.2% but this rate was higher at 30.5% for women attending a Brisbane sexual health clinic and for pregnant women attending the Mater Mothers' antenatal clinic. GBS serovar III has been identified as the dominant serovar in our population group and this strain has been reported as the major cause of GBS disease in neonates and infants aged to three months. Disparity (11.1%) was reported when the incidence of adverse pregnancy outcomes amongst Aboriginal women was compared to non Aboriginal women. From the outcomes of this study it has been suggested that Queensland adopt a screening based GBS preventative protocol. It has also been suggested that an Australian wide GBS prevention strategy may further reduce the incidence of neonatal disease.

A mortalidade neonatal, em vários países do mundo, corresponde ao componente mais expressivo da mortalidade infantil. No Brasil, esta mortalidade mantém-se em patamares elevados e com acentuadas desigualdades regionais em sua distribuição. Este estudo teve como objetivos, analisar a tendência temporal e fatores associados à mortalidade neonatal, identificar padrões na sua distribuição espacial e a relação desta com as condições de vida além de analisar a evolução das desigualdades sociais no risco de morte neonatal e suas relações com características maternas, condições de nascimento, atenção à saúde e de condições de vida em Salvador, Bahia, no período de 1980 a 2006. No primeiro artigo que compõe esta tese, construiu-se uma série temporal dos óbitos neonatais de 1980 a 2006, enquanto nos segundo e terceiro artigos, correspondentes a estudos de agregados espaciais referentes a 2000-2006, Zonas de Informação (ZI) compuseram as unidades de análise. Estas foram agregadas em estratos de elevada, intermediária, baixa e muito baixa condição de vida, com base em um Índice de Condições de Vida. Análise de Componentes Principais, Correlação de Spearman, Regressão Linear ordinal e espacial e Qui-Quadrado de tendência foram métodos empregados na análise dos dados, além do Teste I de Moran (Global e Local) para avaliar dependência espacial, e Risco Relativo, para avaliar as desigualdades sociais. Os resultados demonstraram tendência de estabilização dos óbitos neonatais a partir de 1992 e as três principais causas são redutíveis por adequada atenção à gestação, ao parto e ao recém-nascido. Evidenciou-se autocorrelação espacial entre as taxas (I=0,1717; p=0,0100). O padrão espacial detectado teve a proporção de nascidos vivos (NV) com baixo peso como seu principal fator explicativo e definiu os maiores riscos para esta mortalidade (> 9,0/1000 NV) concentrados em áreas do centro e subúrbio, e os mais baixos (3,2 a 5,5/1000NV) ao sul e leste da cidade. Demonstrou-se associação da mortalidade neonatal com as condições de vida, confirmada pelo gradiente linear e crescente do risco nesta mortalidade do estrato de melhor para o de pior condição de vida, indicando a influência da desigualdade social nesta mortalidade. Há indícios de redução desta desigualdade, devido ao decréscimo ocorrido no estrato de intermediária condição de vida (β= -0,93; 0,039), aliada à reduzida variação no risco de morte neonatal do estrato de elevada condição de vida. São necessárias novas estratégias para a redução da mortalidade neonatal que contemplem maior qualificação e reestruturação da atenção à saúde materno-infantil, bem como outras que promovam melhorias nas condições de vida da população, sob o risco de comprometer a velocidade de decréscimo da mortalidade infantil no município. / Neonatal mortality in several countries of the world corresponds to the major component of infant mortality. In Brazil, this mortality remains at high levels and with marked regional differences in its distribution. This study aimed to analyze the trend and factors associated with neonatal mortality, identify patterns in their spatial distribution and the relationship between living conditions and to analyzing the evolution of social inequalities in risk of neonatal mortality and its relationship to maternal characteristics, conditions of birth, health care and living conditions in Salvador, Bahia, from 1980 to 2006. In the first article that makes up this thesis, we constructed a series of neonatal deaths from 1980 to 2006, whereas in the second and third articles, corresponding to spatial aggregation studies concerning the 2000-2006 period, Information Zones (IZ) were the units analysis. These were aggregated into strata of high, intermediate, low and very low standard of living based on an index of Living Conditions. Principal Component Analysis, Spearman correlation, linear regression, and chi-square test were used in data analysis, besides Moran’s Test I (Global and Local) in order to evaluate spatial dependence, and relative risk for social inequalities evaluation. The results showed a trend towards stabilization of neonatal deaths from 1992 and the three main causes are reducible by adequate attention to pregnancy, labor and the newborn. It was observed autocorrelation between the rates (I = 0.1717, p = 0.0100). The proportion of low birth weight as the main determinant of the spatial pattern detected and defined the greatest risk for infant mortality (>9.0/1000NV) concentrated in the downtown areas and suburbs, and the lowest (3.2 to 5.5/1000NV) to the south and east of the city. It was observed an association between neonatal mortality and living conditions, confirmed by the linear and increasing gradient of mortality risk as we go from the best stratum of living conditions to the worst one, indicating the influence social inequality on neonatal mortality. There is evidence that reducing inequality, due to the decrease occurred in the stratum living conditions (β = -0.93, 0.039), combined with reduced variation in the risk of neonatal death of the stratum living conditions. We need new strategies to reduce neonatal mortality, covering more advanced training and restructuring of attention to maternal and child health, as well as others that promote improvements in living conditions of population at risk of compromising the rate of decrease in infant mortality municipality.

Submitted by MARINA LUCCHINI PONTES NOGUEIRA (malpnogueira@hotmail.com) on 2018-10-15T14:42:37Z No. of bitstreams: 1 Dissertação de Mestrado. Marina Lucchini Pontes Nogueira.pdf: 2279326 bytes, checksum: d24b92bfe972adff14b64721bb4cfb22 (MD5) / Approved for entry into archive by ROSANGELA APARECIDA LOBO null (rosangelalobo@btu.unesp.br) on 2018-10-16T12:58:11Z (GMT) No. of bitstreams: 1 nogueira_mlp_me_bot.pdf: 2279326 bytes, checksum: d24b92bfe972adff14b64721bb4cfb22 (MD5) / Made available in DSpace on 2018-10-16T12:58:11Z (GMT). No. of bitstreams: 1 nogueira_mlp_me_bot.pdf: 2279326 bytes, checksum: d24b92bfe972adff14b64721bb4cfb22 (MD5) Previous issue date: 2018-09-19 / Introdução: O transporte inter-hospitalar de recém-nascidos (RN) para centros terciários muitas vezes é inevitável e está associado a maior o risco para morbidades e para o óbito. A hipótese deste estudo é de que os transportes realizados na região estejam ocorrendo de forma inadequada, piorando o prognóstico dos RN transportados. Objetivos: Determinar o perfil dos RN transportados, avaliar a adequação dos transportes e calcular os escores de risco TRIPS e Ca-TRIPS, correlacionando-os com o risco de óbito e hemorragia peri-intraventricular (HPIV), na primeira semana pós-transporte. Metodologia: Estudo prospectivo de corte transversal, realizado de junho 2014 a dezembro de 2017, incluindo todos os RN submetidos a transporte e internados na Unidade Neonatal do Hospital das Clínicas da Faculdade de Medicina de Botucatu, sem exclusão. As variáveis avaliadas foram: peso ao nascer (PN), idade gestacional (IG), sexo, tipo de parto, apgar, necessidade de reanimação em sala de parto, indicação da transferência, utilização de incubadora apropriada, presença de acesso venoso, drogas e fluidos utilizados, suporte respiratório, tempo de vida à internação, temperatura axilar, padrão respiratório, pressão arterial, uso de drogas vasoativas, estado neurológico e valores dos escores de risco à internação. Os pacientes foram acompanhados na primeira semana pós-transporte em relação à evolução para HPIV ou óbito. Resultados apresentados em tabelas de frequência, com cálculo das médias e desvio padrão ou medianas e percentis; calculados os valores de sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo para os escores. Teste do qui-quadrado foi utilizado no estudo das associações e realizado cálculo do risco relativo para análise dos desfechos (α=0,05). Resultados: Foram estudados 271 RN, a maioria nascidos a termo (medianas de peso: 2975g e IG: 38 semanas). Quase 30% dos pacientes foram transportados da própria cidade de Botucatu, porém 7,7% percorreram distâncias maiores que 150km. O transporte foi inadequado em 86% dos casos: sem incubadora de transporte: 26%; sem acesso venoso: 38%; sem infusão de fluidos: 40%; distermia: 53%; hipo ou hiperglicemia: 33%; hipoxemia: 20%; hipotensão: 19%; bradicardia: 3%. Os valores do TRIPS variaram de 0-65 (mediana: 6) e Ca-TRIPS de 0-60 (mediana: 20) e 31% dos RN apresentaram TRIPS ≥ 10. Valores de TRIPS ≥ 10 foram observados em 27% dos recém-nascidos a termo (RNT) vs 40% dos prematuros (PT) (P=0,04). TRIPS ≥ 10 aumentou o risco de HPIV entre os PT (R.R. = 4,04 - IC95%: 1,23-13,29 – P = 0,023) e o risco de morte entre todos os RN (R.R. = 7,45 - IC95%: 2,87-19,52 - P < 0,001). RN com Ca-TRIPS ≥ 20,5, apresentaram maior risco de morte (R.R. = 13,3 - IC95%: 4,05-43,81 - P < 0,001). Ambos os escores apresentaram valores preditivos positivos e negativos semelhantes. Conclusão: O transporte foi inadequado na maioria dos casos. Embora apenas 30% dos RN tenham sido PT, estes apresentaram valores mais altos de TRIPS e Ca-TRIPS, em comparação aos RNT. Pacientes com escores de risco mais elevados apresentaram maior riscos de óbito e HPIV. / Introduction: Interhospital transport of newborns (NB) to tertiary centers is often unavoidable and associated with greater risk for morbidity and death. The hypothesis of this study is that transport in the region is occurring inadequately, worsening the prognosis of the transported NB. Objectives: To determine the profile of the transported NB, to assess the adequacy of the transports and to calculate the TRIPS and Ca-TRIPS risk scores, correlating them with the risk of death and peri-intraventricular hemorrhage (PIVH) in the first week after transport. Methods: Prospective cross-sectional study, carried out from June 2014 to December 2017, including all NB submitted to transportation and hospitalized at the Neonatal Unit of the Hospital das Clínicas da Faculdade de Medicina de Botucatu, without exclusion. The variables evaluated were: birth weight, gestational age, sex, type of delivery, apgar, need for resuscitation in the delivery room, indication of transference, use of appropriate incubator, presence of venous access, drugs and blood flow used, respiratory support, age at admission, axillary temperature, breathing pattern, blood pressure, use of vasoactive drugs, neurological status, and values of risk scores at the time of admission. Patients were followed in the first post-transport week in relation to the progression to PIVH or death. Results presented in frequency tables, with calculation of means and standard deviation or medians and percentiles; values of sensitivity, specificity, positive predictive value and negative predictive value were calculated for the scores. Chi-square test was used in the study of associations and relative risk (RR) was calculated for the analysis of the outcomes (α=0.05). Results: We studied 271 newborns most born at term (medians weight: 2975g and gestacional age: 38 weeks). Almost 30% of the patients were transported from the city of Botucatu, but 7,7% traveled more than 150km. Transport was inadequate in 86% of cases: without transport incubator: 26%; without venous access: 38%; without fluid infusion: 40%; dysthermia: 53%; hypo or hyperglycemia: 33%; hypoxemia: 20%; hypotension: 19%; bradycardia: 3%. The TRIPS values ranged from 0-65 (median: 6) and Ca-TRIPS from 0-60 (median: 20) and 31% from the NB presented TRIPS ≥10. TRIPS values ≥ 10 were observed in 27% of the full-term newborn vs. 40% of preterm (P = 0.04). TRIPS ≥ 10 increased the risk of PIVH among premature infants (RR = 4.04 - 95% CI: 1.23-13.29 - P = 0.023) and the risk of death among all NB (RR=7,45 – IC95%: 2.87-19.52 - P <0.001). NB with Ca-TRIPS ≥ 20.5 presented higher risk of death (RR=13.3 - 95% CI: 4.05-43.81 - P <0.001). Both scores had similar positive and negative predictive values. Conclusion: Transportation was inadequate in most cases. Although only 30% of the newborns were preterm infants, they presented higher values of TRIPS and Ca-TRIPS compared to the full-term newborns. Patients with higher risk scores had a higher risk of death and PIVH.

Submitted by Keylla Helena Nobre Pacifico Pereira (keylla_pacifico@hotmail.com) on 2018-07-30T15:58:14Z No. of bitstreams: 1 Dissertação mestrado - Keylla 2.docx: 2587623 bytes, checksum: 64380046fdfc8ee53c47fc61f45a0170 (MD5) / Rejected by Ana Lucia de Grava Kempinas (algkempinas@fca.unesp.br), reason: Refazer o upload de arquivo pdf e não word. Está como acesso parcial mas não foi especificado a partir de quando estará disponível na íntegra. Data para a disponibilização do texto completo: on 2018-07-30T18:12:25Z (GMT) / Submitted by Keylla Helena Nobre Pacifico Pereira (keylla_pacifico@hotmail.com) on 2018-07-30T19:56:19Z No. of bitstreams: 1 Dissertação mestrado - Keylla 2.pdf: 1688573 bytes, checksum: 088000530efae82d715bfe0a733942b7 (MD5) / Approved for entry into archive by Ana Lucia de Grava Kempinas (algkempinas@fca.unesp.br) on 2018-07-30T20:43:50Z (GMT) No. of bitstreams: 1 pereira_khnp_me_bot.pdf: 1688573 bytes, checksum: 088000530efae82d715bfe0a733942b7 (MD5) / Made available in DSpace on 2018-07-30T20:43:50Z (GMT). No. of bitstreams: 1 pereira_khnp_me_bot.pdf: 1688573 bytes, checksum: 088000530efae82d715bfe0a733942b7 (MD5) Previous issue date: 2018-07-24 / Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) / A Medicina Veterinária ainda apresenta menores índices de sobrevida neonatal quando comparada à Medicina. O período neonatal em cães possui uma alta taxa de mortalidade e as causas são atribuídas a vários fatores, entre estes a hipoxemia durante o parto e as malformações congênitas. O estudo objetivou avaliar dois fatores para a viabilidade neonatal sendo estes a hipoxemia e os defeitos congênitos. No primeiro estudo, determinou-se e compararou-se a viabilidade neonatal pelo escore de Apgar e reflexos neonatais, entre dois grupos, neonatos que foram submetidos ao clampeamento e neonatos submetidos ao não clampeamento do cordão umbilical. Houve diferença significante no escore Apgar e reflexos entre os grupos, demonstrando uma maior vitalidade neonatal do grupo não clampeado. O segundo estudo avaliou e determinou a incidência de defeitos congênitos encontrados em cães neonatos, relacionou as possíveis causas e determinou a taxa de mortalidade nos recém-nascidos acometidos. Do total de 74 ninhadas com 355 neonatos atendidos, 20 (27%) das ninhadas apresentaram malformações congênitas. As 20 ninhadas possuíam 98 neonatos, dos quais 29 (29,6%) estavam acometidos, e destes, 20 vieram a óbito. O defeito congênito mais comumente encontrado foi a fenda palatina (10/29) 34,5%, seguido pela hidrocefalia (6/29) 20,7%. A taxa de mortalidade total por defeitos congênitos foi de 5,6% (20/355), isto representa 68,9% (20/29) de mortalidade entre os neonatos acometidos. As malformações congênitas em cães possuem incidência significativa e um grande impacto na mortalidade de recém-nascidos. A neonatologia veterinária é uma área em ascensão, as pesquisas na área auxiliarão na intervenção clínica, em melhor qualidade dos tratamentos médicos, na prevenção e com isso maior sobrevida neonatal. As informações obtidas nos presentes estudos auxiliam no diagnóstico, prognóstico e na realização de medidas preventivas durante a gestação, o parto e o período neonatal, minimizando a taxa de mortalidade neonatal canina. / The Veterinary Medicine still has lower rates of neonatal survival when compared to Medicine. The neonatal period in dogs has a high mortality rate and the causes are attributed to several factors, including hypoxemia during birth and congenital malformations. The objective of the study was to evaluate two factors for neonatal viability: hypoxemia and congenital defects. In the first study, neonatal viability was determined and compared with the Apgar score and neonatal reflexes, between two groups, neonates who underwent clamping and neonates submitted to non-clamping of the umbilical cord. There was a significant difference in the Apgar score and reflexes between the groups, demonstrating a greater neonatal vitality of the non-clamped group. The second study evaluated and determined the incidence of congenital defects found in neonatal dogs, related the possible causes and determined the mortality rate in newborns affected. Of the total of 74 litters with 355 newborns attended, 20 (27%) of the litters presented congenital malformations. The 20 litters had 98 neonates, of which 29 (29.6%) were affected, and of these, 20 died. The most commonly found congenital defect was the cleft palate (10/29) 34.5%, followed by hydrocephalus (6/29) 20.7%. The total mortality rate due to congenital defects was 5.6% (20/355), this represents 68.9% (20/29) of mortality among the infants affected. Congenital malformations in dogs have a significant incidence and a great impact on the mortality of newborns. Veterinary neonatology is a growing area, research in the area will aid in clinical intervention, better quality of medical treatments, prevention and with this greater neonatal survival. The information obtained in the present studies helps in the diagnosis, prognosis and in the accomplishment of preventive measures during the gestation, the birth and the neonatal period, minimizing the rate of canine neonatal mortality.

Orientador: João Cesar Lyra / Resumo: Introdução: O transporte inter-hospitalar de recém-nascidos (RN) para centros terciários muitas vezes é inevitável e está associado a maior o risco para morbidades e para o óbito. A hipótese deste estudo é de que os transportes realizados na região estejam ocorrendo de forma inadequada, piorando o prognóstico dos RN transportados. Objetivos: Determinar o perfil dos RN transportados, avaliar a adequação dos transportes e calcular os escores de risco TRIPS e Ca-TRIPS, correlacionando-os com o risco de óbito e hemorragia peri-intraventricular (HPIV), na primeira semana pós-transporte. Metodologia: Estudo prospectivo de corte transversal, realizado de junho 2014 a dezembro de 2017, incluindo todos os RN submetidos a transporte e internados na Unidade Neonatal do Hospital das Clínicas da Faculdade de Medicina de Botucatu, sem exclusão. As variáveis avaliadas foram: peso ao nascer (PN), idade gestacional (IG), sexo, tipo de parto, apgar, necessidade de reanimação em sala de parto, indicação da transferência, utilização de incubadora apropriada, presença de acesso venoso, drogas e fluidos utilizados, suporte respiratório, tempo de vida à internação, temperatura axilar, padrão respiratório, pressão arterial, uso de drogas vasoativas, estado neurológico e valores dos escores de risco à internação. Os pacientes foram acompanhados na primeira semana pós-transporte em relação à evolução para HPIV ou óbito. Resultados apresentados em tabelas de frequência, com cálculo das médias e desvio ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Interhospital transport of newborns (NB) to tertiary centers is often unavoidable and associated with greater risk for morbidity and death. The hypothesis of this study is that transport in the region is occurring inadequately, worsening the prognosis of the transported NB. Objectives: To determine the profile of the transported NB, to assess the adequacy of the transports and to calculate the TRIPS and Ca-TRIPS risk scores, correlating them with the risk of death and peri-intraventricular hemorrhage (PIVH) in the first week after transport. Methods: Prospective cross-sectional study, carried out from June 2014 to December 2017, including all NB submitted to transportation and hospitalized at the Neonatal Unit of the Hospital das Clínicas da Faculdade de Medicina de Botucatu, without exclusion. The variables evaluated were: birth weight, gestational age, sex, type of delivery, apgar, need for resuscitation in the delivery room, indication of transference, use of appropriate incubator, presence of venous access, drugs and blood flow used, respiratory support, age at admission, axillary temperature, breathing pattern, blood pressure, use of vasoactive drugs, neurological status, and values of risk scores at the time of admission. Patients were followed in the first post-transport week in relation to the progression to PIVH or death. Results presented in frequency tables, with calculation of means and standard deviation or medians and percentiles; values of sensiti... (Complete abstract click electronic access below) / Mestre

A mortalidade neonatal, em vários países do mundo, corresponde ao componente mais expressivo da mortalidade infantil. No Brasil, esta mortalidade mantém-se em patamares elevados e com acentuadas desigualdades regionais em sua distribuição. Este estudo teve como objetivos, analisar a tendência temporal e fatores associados à mortalidade neonatal, identificar padrões na sua distribuição espacial e a relação desta com as condições de vida além de analisar a evolução das desigualdades sociais no risco de morte neonatal e suas relações com características maternas, condições de nascimento, atenção à saúde e de condições de vida em Salvador, Bahia, no período de 1980 a 2006. No primeiro artigo que compõe esta tese, construiu-se uma série temporal dos óbitos neonatais de 1980 a 2006, enquanto nos segundo e terceiro artigos, correspondentes a estudos de agregados espaciais referentes a 2000-2006, Zonas de Informação (ZI) compuseram as unidades de análise. Estas foram agregadas em estratos de elevada, intermediária, baixa e muito baixa condição de vida, com base em um Índice de Condições de Vida. Análise de Componentes Principais, Correlação de Spearman, Regressão Linear ordinal e espacial e Qui-Quadrado de tendência foram métodos empregados na análise dos dados, além do Teste I de Moran (Global e Local) para avaliar dependência espacial, e Risco Relativo, para avaliar as desigualdades sociais. Os resultados demonstraram tendência de estabilização dos óbitos neonatais a partir de 1992 e as três principais causas são redutíveis por adequada atenção à gestação, ao parto e ao recém-nascido. Evidenciou-se autocorrelação espacial entre as taxas (I=0,1717; p=0,0100). O padrão espacial detectado teve a proporção de nascidos vivos (NV) com baixo peso como seu principal fator explicativo e definiu os maiores riscos para esta mortalidade (> 9,0/1000 NV) concentrados em áreas do centro e subúrbio, e os mais baixos (3,2 a 5,5/1000NV) ao sul e leste da cidade. Demonstrou-se associação da mortalidade neonatal com as condições de vida, confirmada pelo gradiente linear e crescente do risco nesta mortalidade do estrato de melhor para o de pior condição de vida, indicando a influência da desigualdade social nesta mortalidade. Há indícios de redução desta desigualdade, devido ao decréscimo ocorrido no estrato de intermediária condição de vida (β= -0,93; 0,039), aliada à reduzida variação no risco de morte neonatal do estrato de elevada condição de vida. São necessárias novas estratégias para a redução da mortalidade neonatal que contemplem maior qualificação e reestruturação da atenção à saúde materno-infantil, bem como outras que promovam melhorias nas condições de vida da população, sob o risco de comprometer a velocidade de decréscimo da mortalidade infantil no município. / Neonatal mortality in several countries of the world corresponds to the major component of infant mortality. In Brazil, this mortality remains at high levels and with marked regional differences in its distribution. This study aimed to analyze the trend and factors associated with neonatal mortality, identify patterns in their spatial distribution and the relationship between living conditions and to analyzing the evolution of social inequalities in risk of neonatal mortality and its relationship to maternal characteristics, conditions of birth, health care and living conditions in Salvador, Bahia, from 1980 to 2006. In the first article that makes up this thesis, we constructed a series of neonatal deaths from 1980 to 2006, whereas in the second and third articles, corresponding to spatial aggregation studies concerning the 2000-2006 period, Information Zones (IZ) were the units analysis. These were aggregated into strata of high, intermediate, low and very low standard of living based on an index of Living Conditions. Principal Component Analysis, Spearman correlation, linear regression, and chi-square test were used in data analysis, besides Moran’s Test I (Global and Local) in order to evaluate spatial dependence, and relative risk for social inequalities evaluation. The results showed a trend towards stabilization of neonatal deaths from 1992 and the three main causes are reducible by adequate attention to pregnancy, labor and the newborn. It was observed autocorrelation between the rates (I = 0.1717, p = 0.0100). The proportion of low birth weight as the main determinant of the spatial pattern detected and defined the greatest risk for infant mortality (>9.0/1000NV) concentrated in the downtown areas and suburbs, and the lowest (3.2 to 5.5/1000NV) to the south and east of the city. It was observed an association between neonatal mortality and living conditions, confirmed by the linear and increasing gradient of mortality risk as we go from the best stratum of living conditions to the worst one, indicating the influence social inequality on neonatal mortality. There is evidence that reducing inequality, due to the decrease occurred in the stratum living conditions (β = -0.93, 0.039), combined with reduced variation in the risk of neonatal death of the stratum living conditions. We need new strategies to reduce neonatal mortality, covering more advanced training and restructuring of attention to maternal and child health, as well as others that promote improvements in living conditions of population at risk of compromising the rate of decrease in infant mortality municipality.

Orientador: Maria Lúcia Gomes Lourenço / Resumo: A Medicina Veterinária ainda apresenta menores índices de sobrevida neonatal quando comparada à Medicina. O período neonatal em cães possui uma alta taxa de mortalidade e as causas são atribuídas a vários fatores, entre estes a hipoxemia durante o parto e as malformações congênitas. O estudo objetivou avaliar dois fatores para a viabilidade neonatal sendo estes a hipoxemia e os defeitos congênitos. No primeiro estudo, determinou-se e compararou-se a viabilidade neonatal pelo escore de Apgar e reflexos neonatais, entre dois grupos, neonatos que foram submetidos ao clampeamento e neonatos submetidos ao não clampeamento do cordão umbilical. Houve diferença significante no escore Apgar e reflexos entre os grupos, demonstrando uma maior vitalidade neonatal do grupo não clampeado. O segundo estudo avaliou e determinou a incidência de defeitos congênitos encontrados em cães neonatos, relacionou as possíveis causas e determinou a taxa de mortalidade nos recém-nascidos acometidos. Do total de 74 ninhadas com 355 neonatos atendidos, 20 (27%) das ninhadas apresentaram malformações congênitas. As 20 ninhadas possuíam 98 neonatos, dos quais 29 (29,6%) estavam acometidos, e destes, 20 vieram a óbito. O defeito congênito mais comumente encontrado foi a fenda palatina (10/29) 34,5%, seguido pela hidrocefalia (6/29) 20,7%. A taxa de mortalidade total por defeitos congênitos foi de 5,6% (20/355), isto representa 68,9% (20/29) de mortalidade entre os neonatos acometidos. As malformações congêni... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The Veterinary Medicine still has lower rates of neonatal survival when compared to Medicine. The neonatal period in dogs has a high mortality rate and the causes are attributed to several factors, including hypoxemia during birth and congenital malformations. The objective of the study was to evaluate two factors for neonatal viability: hypoxemia and congenital defects. In the first study, neonatal viability was determined and compared with the Apgar score and neonatal reflexes, between two groups, neonates who underwent clamping and neonates submitted to non-clamping of the umbilical cord. There was a significant difference in the Apgar score and reflexes between the groups, demonstrating a greater neonatal vitality of the non-clamped group. The second study evaluated and determined the incidence of congenital defects found in neonatal dogs, related the possible causes and determined the mortality rate in newborns affected. Of the total of 74 litters with 355 newborns attended, 20 (27%) of the litters presented congenital malformations. The 20 litters had 98 neonates, of which 29 (29.6%) were affected, and of these, 20 died. The most commonly found congenital defect was the cleft palate (10/29) 34.5%, followed by hydrocephalus (6/29) 20.7%. The total mortality rate due to congenital defects was 5.6% (20/355), this represents 68.9% (20/29) of mortality among the infants affected. Congenital malformations in dogs have a significant incidence and a great impact on the mortalit... (Complete abstract click electronic access below) / Mestre

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / INTRODUÃÃO: O Brasil, acompanhando a tendÃncia mundial, experimentou uma reduÃÃo marcante na mortalidade infantil, mas uma forÃa de declÃnio de igual valor nÃo foi percebida na taxa de mortalidade neonatal, sugerindo falhas na qualidade da assistÃncia obstÃtrica e neonatal. As desigualdades nacionais e regionais, o acesso limitado aos cuidados necessÃrios, a iniquidade na distribuiÃÃo de leitos intensivos neonatais e a fragilidade dos serviÃos prestados, contribuem como fatores associados ao risco de morte infantil no perÃodo neonatal. OBJETIVOS: Avaliar os fatores associados à mortalidade intra-hospitalar no perÃodo neonatal, utilizando como variÃveis explicativas as caracterÃsticas individuais relacionadas à mÃe e aos recÃm-nascidos internados em Unidades Neonatais de Alto Risco (UTIN) integrantes da RENOSPE no Nordeste do Brasil e caracterizar as UTIN em relaÃÃo aos indicadores de qualidade no atendimento obstÃtrico e neonatal. METODOLOGIA: Delineou-se estudo longitudinal, multicÃntrico de base hospitalar entre recÃm-nascidos, cujas unidades de anÃlise foram as UTIN dos estados do Nordeste brasileiro. A populaÃÃo do estudo compreendeu 3.623 nascidos vivos internados em UTIN das instituiÃÃes hospitalares das nove Unidades Federadas do Nordeste do Brasil e integrantes da RENOSPE. Os dados individuais do modelo hierarquizado foram obtidos do formulÃrio: Pesquisa: DiagnÃstico da Qualidade da AtenÃÃo Perinatal em InstituiÃÃes de SaÃde Participantes da RENOSPE. Para a anÃlise foi utilizado modelo hierÃrquico em trÃs nÃveis: nÃvel distal (caracterÃsticas sociais, econÃmicas e demogrÃficas), nÃvel intermediÃrio I(caracterÃsticas maternas) e II (assistÃncia prÃ-natal e ao parto) e nÃvel proximal (condiÃÃes de saÃde do nascido vivo e da atenÃÃo neonatal - uso de tecnologias). Foram selecionados sete indicadores de qualidade do atendimento obstÃtrico e neonatal: Iniciativa Maternidade Segura; Iniciativa Hospital Amigo da CrianÃa; Programa atendimento da gestante de alto risco; UTIN interditada nos Ãltimos 12 meses; UTIN superlotaÃÃo nos Ãltimos 12 meses; AdoÃÃo do MÃtodo Canguru na assistÃncia ao recÃm-nascido; Estabelecimento de saÃde com Protocolo de IntervenÃÃo MÃnima para Prematuro com peso inferior a 1.250g. RESULTADOS: ApÃs o ajuste para os trÃs nÃveis hierÃrquicos do modelo de determinaÃÃo do Ãbito ocorrido em UTIN, as variÃveis que compuseram o modelo hierarquizado final da regressÃo logÃstica multivariada foram: i) parto cesÃrea (OR ajustada=0,72; IC95% 0,56-0,95; p=0,019); ii) nÃo utilizaÃÃo de corticÃide antenatal entre recÃm-nascidos com peso inferior a 1.500g (OR ajustada=1,51; IC95% 1,01-2,25; p=0,041); iii) prÃ-eclampsia (OR ajustada=0,73; IC95% 0,56-0,95; p=0,020); iv) oligodramnia (OR ajustada=1,57; IC95% 1,17-2,10; p=0,002); v) peso inferior a 2500g (OR ajustada=1,40; IC95% 1,03-1,90; p=0,027); vi) escore de Apgar 5 minuto de vida inferior a sete (OR ajustada=2,63; IC95% 2,21-3,14; p<0,001); vii) uso de tubo endotraqueal (OR ajustada=1,95; IC95% 1,31-2,91; p=0,001); viii) nÃo uso de surfactante entre recÃm-nascidos com peso inferior a 1.500g (OR ajustada=0,54; IC95% 0,43-0,69; p<0,001). A relaÃÃo entre a variÃvel independente uso de surfactante, apesar de apresentar associaÃÃo protetora entre aqueles que nÃo utilizaram a referida tecnologia, esse significado nÃo nos pareceu com caracterÃsticas espÃrias, haja vista que os que utilizaram, o fizeram por apresentarem-se mais gravemente enfermos. Em relaÃÃo aos sete indicadores de qualidade das instituiÃÃes hospitalares e UTIN, destaca-se um cenÃrio de superlotaÃÃo e interdiÃÃo, em meio Ãs iniciativas positivas de incentivo ao aleitamento materno exclusivo e mÃtodo MÃe Canguru. Esses dados reforÃam que as causas de morte intra-hospitalar ocorrido no perÃodo neonatal, sÃo determinadas principalmente pela qualidade e condiÃÃes de assistÃncia à gestaÃÃo e ao parto e ao recÃm-nascido, dependendo de fortalecimento na organizaÃÃo da rede assistencial. / INTRODUCTION: Brazil, following the global trend, experienced a marked reduction in infant mortality, but a force of equal value decline was not seen in the neonatal mortality rate, suggesting gaps in the quality of obstetric and neonatal care. National and regional inequalities, limited access to care, inequity in the distribution of beds and the fragility of neonatal intensive services, contributing factors associated with the risk of infant death in the neonatal period. OBJECTIVES: To evaluate the factors associated with in-hospital mortality in the neonatal period, using as explanatory variables individual characteristics related to the mother and the newborns hospitalized in High Risk Neonatal Units (NICU) members RENOSPE in northeastern Brazil and characterize NICU for indicators of quality in obstetric and neonatal care. METHODOLOGY: The design of this study was longitudinal, multicenter hospital-based among newborns, the units of analysis were the NICU states of the Brazilian Northeast. The study population comprised 3,623 live births admitted to NICU of hospitals from nine federal units of Northeast Brazil and members of RENOSPE. Individual data were obtained from the hierarchical model of the form: Search: Diagnostic Quality of Care in Perinatal Health Care Participants RENOSPE. For the analysis model was used in three hierarchical levels: the distal level (social, economic and demographic), intermediate I (maternal characteristics) and II (prenatal care and childbirth) and the proximal (health conditions live birth and neonatal care - use of technologies). We selected seven indicators of quality of obstetric and neonatal: Safe Motherhood Initiative, the Baby Friendly Hospital Initiative; Program attendance of high risk pregnancies; NICU banned in the past 12 months; NICU overcrowding in the last 12 months; Adoption of Kangaroo Care assistance the newborn; health establishment with Protocol Minimal Intervention for Premature weighing less than 1.250g. RESULTS: After adjustment for the three-level hierarchical model for the determination of death occurring in the NICU, the variables that compose the hierarchical model of the final multivariate logistic regression were: i) cesarean delivery (adjusted OR = 0.72, 95% CI 0, 56 to 0.95, p = 0.019), ii) non-use of antenatal corticosteroids among infants born weighing less than 1,500 g (adjusted OR = 1.51, 95% CI 1.01 to 2.25, p = 0.041) iii) pre-eclampsia (adjusted OR = 0.73, 95% CI 0.56 to 0.95, p = 0.020), iv) oligohydramnios (adjusted OR = 1.57, 95% CI 1.17 to 2.10; p = 0.002), v) weighing less than 2,500 g (adjusted OR = 1.40, 95% CI 1.03 to 1.90, p = 0.027); vi) Apgar score 5 minutes of life less than seven (adjusted OR = 2.63, 95% CI 2.21 to 3.14, p <0.001), vii) endotracheal intubation (adjusted OR = 1.95, 95% CI 1.31 to 2.91, p = 0.001), viii) no surfactant use among newborns weighing less than 1,500 g (adjusted OR = 0.54, 95% CI 0.43-0.69, p <0.001). The relationship between the independent variable surfactant use, despite a protective association among those who did not use such technology, meaning that it did not seem to spurious features, given that they have used, did they present themselves more seriously ill. Concerning the seven indicators of quality in hospitals and NICU, there is a scenario of overcrowding and interdiction, amid positive initiatives to encourage exclusive breastfeeding and kangaroo mother method. These data reinforce the causes of in-hospital death occurred in the neonatal period, are primarily determined by the quality and conditions of care during pregnancy and childbirth, and the newborn, depending on strengthening the organization of health care network.

nÃo hà / A mortalidade neonatal sofre influÃncia de uma complexa relaÃÃo de fatores socioeconÃmicos, assistenciais e biolÃgicos. Nas duas Ãltimas dÃcadas a mortalidade nos perÃodos peri e neonatal nÃo sofreu declÃnio significativo, devido à permanÃncia dos elevados nÃveis de mortalidade por fatores ligados à gestaÃÃo e ao parto. Atualmente, a mortalidade neonatal representa 60% a 70% da mortalidade infantil em todas as regiÃes brasileiras. Estudos desenhados para investigar os fatores determinantes da mortalidade neonatal tÃm sido amplamente desenvolvidos no Brasil, no entanto, estudos do tipo caso controle utilizando dados primÃrios nÃo foram desenvolvidos na cidade de Fortaleza-Ce nos Ãltimos anos. O estudo objetivou determinar os fatores associados aos Ãbitos neonatais em Fortaleza-Ce no ano de 2009. ConstituÃram os objetivos especÃficos dessa casuÃstica: descrever as caracterÃsticas socioeconÃmicas e demogrÃficas das mÃes e dos recÃm-nascidos para os casos (Ãbitos neonatais) e os controles (recÃm-nascidos sobreviventes), identificar as caracterÃsticas relacionadas à assistÃncia prÃ-natal, parto e ao recÃm-nascido dos Ãbitos neonatais e dos recÃm-nascidos sobreviventes e determinar os fatores preditores da mortalidade neonatal utilizando modelagem hierarquizada. Quanto aos aspectos metodolÃgicos, tratou-se de um estudo do tipo caso-controle, com 132 casos de Ãbitos neonatais e 264 controles obtidos entre os sobreviventes ao perÃodo neonatal. Para os casos foram consideradas as crianÃas nascidas vivas e que morreram antes de completar 28 dias de vida e como controles as que permaneceram vivas neste perÃodo, nascidas em Fortaleza-Ce e filhos de mÃes residentes no municÃpio. As informaÃÃes foram obtidas atravÃs de entrevistas domiciliares por meio de questionÃrio estruturado. As variÃveis foram agrupadas em quatro blocos hierÃrquicos de acordo com modelo conceitual: bloco1-caracterÃsticas socioeconÃmicas e demogrÃficas; bloco2-caracterÃsticas maternas, histÃria reprodutiva, morbidade materna, comportamento materno, apoio social e exposiÃÃo à violÃncia; bloco 3-caracterÃsticas da assistÃncia no prÃ-natal e parto; bloco 4-sexo e condiÃÃes de saÃde do recÃm-nascido. O modelo de anÃlise de regressÃo logÃstica hierarquizada identificou como fatores associados ao Ãbito neonatal: bloco 1- raÃa materna com efeito protetor para raÃa parda e negra (OR: 0,23; IC 95% 0,09-0,56); bloco 3- tempo gasto entre o deslocamento de casa ao hospital igual ou superior a 30 minutos (OR: 3,12; IC 95% 1,34-7,25), tempo inferior à 1 hora ou superior ou igual a 10 horas entre a internaÃÃo e o parto (OR: 2,43; IC 95% 1,24-4,76) e prÃ-natal inadequado (OR: 2,03; IC 95% 1,03-3,99); bloco 4- baixo peso ao nascer (OR:14,75; IC 95% 5,26-41,35), prematuridade (OR: 3,41; IC 95% 1,29-8,98 ) e sexo masculino (OR: 2,09; IC 95% 1,09-4,03). Essa casuÃstica revelou aspectos na determinaÃÃo das mortes neonatais relacionados à qualidade da assistÃncia prÃ-natal oferecida Ãs gestantes, à oferta dos leitos hospitalares, indicando a peregrinaÃÃo das gestantes em busca de maternidades, bem como aspectos relacionados à assistÃncia direta ao trabalho de parto, traduzido pelo determinante tempo superior a 10 horas decorrido entre a internaÃÃo da gestante e o parto. / Neonatal mortality is influenced by a complex interplay of socioeconomic, biological and social assistance. In the last two decades the mortality in the perinatal and neonatal periods not suffered significant declines, due to persistent high levels of mortality factors related to pregnancy and childbirth. Currently, neonatal mortality accounts for 60% to 70% of infant mortality in all regions of Brazil. Studies designed to investigate the determinants of neonatal mortality have been widely developed in Brazil, however, case-control studies using primary data have not been developed in the city of Fortaleza-Ce in recent years. The study aimed to determine factors associated with neonatal deaths in Fortaleza in 2009. Were the specific objectives of this series to describe the socioeconomic and demographic characteristics of mothers and newborns in cases (neonatal deaths) and controls (newborn survivors), to identify the features related to prenatal care, childbirth and newborn and neonatal deaths of infants surviving and determine predictors of neonatal mortality using hierarchical modeling. Methodological terms, this was a study of case-control, with 132 cases of neonatal deaths and 264 controls obtained among survivals of the neonatal period. For cases were considered children born alive and died before 28 days of life and how those controls remained alive during this period, born in Fortaleza-Ce and children of mothers living in the city. The information was obtained through home interviews using a structured questionnaire. Variables were grouped into four groups according to hierarchical conceptual model: Block 1-socioeconomic and demographic characteristics; bloco2-maternal characteristics, reproductive history, maternal morbidity, maternal behavior, social support and exposure to violence; 3-block handling characteristics of the pre prenatal and childbirth; block 4-sex and health of the newborn. The model of hierarchical logistic regression analysis identified factors associated with neonatal death: Block 1 - maternal race with a protective effect against brown and black race (OR: 0.23, 95% CI 0.09 to 0.56), block 3 - between the time spent commuting from home to hospital less than 30 minutes (OR: 3.12, 95% CI 1.34 to 7.25), less than 1 hour or greater than or equal to 10 hours between admission and delivery (OR: 2.43, 95% CI 1.24 to 4.76) and inadequate prenatal care (OR: 2.03, 95% CI 1.03 to 3.99) Block 4 - low weight birth (OR: 14.75, 95% CI 5.26 to 41.35), prematurity (OR: 3.41, 95% CI 1.29 to 8.98) and male (OR: 2.09, CI 95% 1.09 to 4.03). This series has revealed aspects of the determination of neonatal deaths related to the quality of prenatal care offered to pregnant women, supply of hospital beds, indicating the pilgrimage of pregnant women seeking maternity, as well as aspects related to direct assistance to labor, translated determining the time over 10 hours elapsed between admission and delivery in pregnant women.