Mortalidade infantil no Distrito Federal: panorama antes, durante e após a pandemia da Covid-19

Abstract

Introduction: Infant mortality is one of the most sensitive indicators of the population's living conditions and the quality of health care, as it reflects social and economic determinants as well as the organization of health systems. In recent decades, Brazil has made substantial progress in reducing this indicator; however, relevant regional and social inequalities persist. The COVID-19 pandemic represented a disruptive event for health systems worldwide, leading to the reorganization of service delivery, overload of health care networks, and potential indirect impacts on maternal and child health care, especially regarding access to essential actions such as prenatal care, childcare follow-up, and pediatric consultations. In addition to the effects observed during the acute phase of the health crisis, its impacts may manifest later, in the post-pandemic period, due to the accumulated discontinuity of care and the weakening of essential child follow-up actions. Despite its relatively high Human Development Index, the Federal District presents internal heterogeneities that make the monitoring of infant mortality relevant in contexts of health crisis. Objective: To compare the infant mortality rate in the Federal District during the pre-pandemic (2018-2019), pandemic (2020-2021), and post-pandemic (2022-2023) periods, analyzing its components, maternal and perinatal characteristics of infant deaths, distribution by underlying causes, and classification according to preventable causes. Method: This was an ecological, analytical, retrospective, population-based study with temporal analysis, developed using secondary data from the Mortality Information System (SIM) and the Live Birth Information System (SINASC), referring to infant deaths among residents of the Federal District between 2018 and 2023. Live births were used as the denominator to calculate the Infant Mortality Coefficient (IMC) and its components: early neonatal (0—6 days), Iate neonatal (7—27 days), and post-neonatal (28—364 days). Ninety-five percent confidence intervals were estimated using the Poisson method. The association between period and IMC was estimated using Poisson regression with na offset term (logarithm of live births), with robust variance, producing Incidence Rate Ratios (IRR) with 95%CI, in crude models and models adjusted for linear trend. Maternal and perinatal characteristics and causes of death were compared between periods using Pearson's chi-square test, with a 5% significance level. Results: A total of 3,524 infant deaths and 235,492 live births were analyzed. The mean IMC over the total period was 14.96/1,000 live births (LB), with a progressive increase across periods: 14.19/1,000 LB in the pre-pandemic period, 14.68/1,000 LB in the pandemic period, and 16.21/1,000 LB in the post-pandemic period (95%CI: 15.29—17.18). The post-pandemic period was associated with a 14.3% higher rate ratio of infant death compared with the reference period (IRR = 1.143; 95%CI: 1.033—1.265; p = 0.010), whereas the pandemic period did not show a statistically significant difference from the pre-pandemic period in the crude model (IRR = 1.034; 95%CI: 0.925—1.157; p = 0.552). After adjustment for trend, both periods showed a significant association, and the linear trend indicated a 2.9% annual increase (IRR = 1.029; 95%CI: 1.017—1.040; p < 0.001). The post-neonatal component (28—364 days) showed the largest absolute increase in mortality rate, rising from 3.38/1,000 LB in the pre-pandemic period to 3.62/1,000 LB in the pandemic period and 4.60/1,000 LB in the post-pandemic period, as well as the highest rate ratio in the crude model (IRR = 1.361; 95%CI: 1224—1513; p < 0.001). The distribution of infant deaths by gestational age (p = 0.010), birth weight (p = 0.021), and underlying causes of death (p = 0.010) showed statistical differences between periods, with a proportional increase in deaths among children with gestational age <22 weeks, term births, and adequate birth weight in the post-pandemic period. The distribution of deaths according to preventable causes differed significantly between periods (p = 0.009), with an increase in the proportion of deaths not classified as preventable from 47.11% in the pre-pandemic period to 53.24% in the post-pandemic period, and a reduction in deaths reducible by adequate care for newborns from 16.19% to 11.73%. Conclusions: Infant mortality in the Federal District showed an upward trajectory throughout the pandemic cycle, with a more pronounced association in the post-pandemic period, driven mainly by the post-neonatal component. The observed pattern suggests apossible weakening of primary health care and childcare follow-up services throughout the health crisis, evidenced especially by the behavior of potentially preventable causes of death. The Hndings reinforce the need for sustained strategies to strengthen maternal and child health care, death surveillance, and the reduction of inequities in access to care,with continuous monitoring of the IMC and its components as an essential tool for health management and planning.