Neonatal near miss determinants at a maternity hospital for high-risk pregnancy in Northeastern Brazil: a prospective study

Background: To investigate the associations of maternal variables - sociodemographic, obstetrical and maternal near miss (MNM) variables - with neonatal near miss (NNM) using the new concept of NNM formulated by the Centro Latino-Americano de Perinatologia (CLAP) and the corresponding health indicators for NNM. Methods: An analytical prospective cohort study was performed at maternity hospital for high-risk pregnancy in Northeastern Brazil. Puerperal women whose newborn infants met the selection criteria were subjected to interviews involving pretested questionnaires. Statistical analysis was performed with the Epi Info 3.5.1 program using the Chi square test and Fisher's exact test when appropriate, with a level of significance of 5%. A bivariate analysis was performed to evaluate differences between the groups. All the variables evaluated in the bivariate analysis were subsequently included in the multivariate analysis. For stepwise logistic regression analysis, a hierarchical model was plotted to assess variable responses and adverse outcomes associated with MNM and NNM variables. Results: There were 1002 live births (LB) from June 2015 through May 2016, corresponding to 723 newborn infants (72.2%) without any neonatal adverse outcomes, 221 (22%) NNM cases, 44 (4.4%) early neonatal deaths and 14 (1.4%) late neonatal deaths. The incidence of NNM was 220/1000 LB. Following multivariate analysis, the factors that remained significantly associated with increased risk of NNM were fewer than 6 prenatal care visits (odds ratio (OR): 3.57; 95% confidence interval (CI): 2.57-4.94) and fetal malformations (OR: 8.78; 95% CI: 3.69-20.90). Maternal age older than 35 years (OR: 0.43; 95% CI: 0.23-0.83) and previous cesarean section (OR: 0.45; 95% CI: 0.29-0.68) protected against NNM. Conclusion: Based on the large differences between the NNM and neonatal mortality rates found in the present study and the fact that NNM seems to be a preventable precursor of neonatal death, we suggest that all cases of NNM should be audited. Inadequate prenatal care and fetal malformations increased the risk of NNM, while older maternal age and a history of a previous cesarean section were protective factors.