Higher perinatal mortality in National Public Health System hospitals in Belo Horizonte, Brazil, 1999: a compositional or contextual effect?
OBJECTIVE
In Brazil, it was previously reported that in hospital perinatal, neonatal and infant mortality rates are higher for hospitals contracted to the National Public Health System (SUS) compared with non-SUS hospitals. We analyse whether this reflects a compositional effect (selection of patients) or a contextual effect.


METHODS
Population-based cohort study.


METHODS
Belo Horizonte, Brazil, 1999.


METHODS
A total of 36,469 births in 24 hospitals.


METHODS
A multilevel analysis was carried out using information gathered at the individual level on maternal education (used as an indicator of socio-economic status), maternal age, type of pregnancy and delivery, birthweight and sex of the fetus.


METHODS
Perinatal death.


RESULTS
Risk factors for perinatal death included male sex (OR = 1.25; 95% CI 1.01-1.55), birthweight of 1500-2500 g (OR = 7.65; 95% CI 5.74-10.20), birthweight of 500-1500 g (OR = 187.54; 95% CI 141.31-248.39), less than 4 years of maternal education (OR = 2.93; 95% CI 1.68-5.10), as well as birth at private-SUS (OR = 2.92; 95% CI 1.87-4.54) or philanthropic-SUS hospitals (OR = 1.81; 95% CI 1.12-2.92). After controlling for individual characteristics, there was still a significant variation in perinatal deaths between hospitals categories.


CONCLUSIONS
Independent of compositional (or individual) characteristics, hospital factors exert an influence on the risk of perinatal death, primarily hospital category related to SUS. Considering the highest proportion of births in SUS hospitals in Brazil, especially private-SUS hospitals, improving hospital quality of care is an urgent priority for reducing the toll of perinatal and infant mortality, as well as inequalities in these outcomes.
Lansky
S
S
Belo Horizonte Health Department, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. slansky@uol.com.br
Subramanian
S V
SV
França
E
E
Kawachi
I
I
D001724:Birth Weight; D001938:Brazil / Q000453:epidemiology; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006779:Hospitals, Public / Q000706:statistics & numerical data*; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D016017:Odds Ratio; D011247:Pregnancy; D011256:Pregnancy Outcome