O2045: Perinatal Outcomes in Brazil: The Impact of Time, Region, and Municipal Income Level on Stillbirth and Neonatal Mortality

Background: Over 2.4 million neonatal deaths and 2.6 million stillbirths occur each year. The vast majority of this perinatal losses occur in low- and middle-income countries (LMICs). In 2014 the World Health Organization (WHO) released the “Every Newborn Action Plan”, which set a target of 12 or fewer neonatal deaths per 1000 live births and 12 or fewer stillbirths per 1000 total births in all countries by 2030. Brazil is an upper middle-income country, as defined by the World Bank Group, yet is home to significant wealth inequality and social inequity. Nationally, Brazil has seen great improvement in its perinatal outcomes and is no longer one of the top 10 contributing countries to the global neonatal mortality or stillbirth burden, but less data exists on the impact of regional socioeconomic status on birth outcomes. With this context, the aims of this study were 1) to detail regional trends in stillbirth and perinatal mortality across Brazil from 2000-2019 and 2) analyze the effect of municipal wealth status on perinatal outcomes.

Methods: We conducted a longitudinal, ecological cohort study based on publicly available and regularly collected data from within the Brazilian healthcare system via the Live birth Information System and Mortality Information System. Data collected between 2000 and 2019 were analyzed at the municipality level. Stillbirths, live births, and subsequent neonatal deaths were recorded. Outcome rates were subdivided by weeks of gestation. Municipalities were categorized as “high-income”, “upper middle-income” and “lower middle-income” based on World Bank Group Classifications.

Results: A total of 60.8 million records were included, with 59.2 million live births and 656,584 stillbirths analyzed. Time trends since 2000 show decreasing neonatal mortality and stillbirth across gestational ages (Figure 1). For infants delivered after 28 weeks, Brazil has met WHO targets since 2000. The most rapid improvements were seen between 2008 and 2010. When infants born at 22-27 weeks gestation are included, 2019 values show worse perinatal outcomes with a neonatal mortality rate of 12.4 3 and stillbirth rate of 10.21. National variation in outcomes exist and parallel regional wealth inequality, with the North region reporting a 2019 neonatal mortality rate of 15.17, compared to 10.25 in the Southeast. Analysis based on municipal economic status for infants 28 weeks gestation and older reveals that high-income municipalities have neonatal mortality and stillbirth rates of 6.43 and 5.22, respectively. In contrast, lower-middle income regions have corresponding rates of 8.69 and 8.47 (Figure 2).

Conclusion: Brazil has made significant progress from 2000-2019 in neonatal mortality and stillbirth. Ongoing improvement is needed in infants born below 28 weeks gestation. Across Brazil, significant inequity exists based on municipal economic status. These remaining gaps in outcome measures can inform regional and national health policy and programing related to perinatal care.