Preterm birth is a major cause of neonatal morbidity and mortality worldwide. Classically defined as the birth that occurs before the 37th
week of pregnancy [1
], it is also the main responsible for deficiencies acquired after birth. Except for congenital malformations, 75% of perinatal deaths and 50% of neurological abnormalities are directly attributed to preterm [2
Thanks to advances in technology and improvements in health care, several preterm newborn infants survive with least sequelae. However, many of them remain vulnerable to long term complications that may persist all over their lives. Among the main resulting morbidities are neurosensory deficits (blindness, deafness), necrotizing enterocolitis, intraventricular hemorrhage, and delay in physical and mental development [5
In a recent publication, the United States' Institute of Medicine reported that the incidence of preterm birth has increased in the last two decades [7
]. Preterm newborn infants represented 9.4% of live births in the United States in 1981. In 2004, this proportion increased to 12.5% [8
]. Other data from the United States confirmed these figures, showing that, in 2006, 12.8% of births were preterm, which represented a 21% increase compared to 1990 [4
]. This fact has greatly motivated the interest from authorities and those responsible for the different sectors of maternal-infant health, either public or private, in several countries of the world.
Preterm births are spontaneous in 75% of the cases [9
]. Of those resulting from medical indication, more than half are associated with pre-eclampsia, fetal distress, intrauterine growth restriction, abruptio placentae, and placental insufficiency [10
]. Although the preterm birth etiology is heterogeneous, it has known associated risk factors. Notable among these factors are previous spontaneous preterm labor, low socioeconomic level, and the interaction between genetic and environmental factors.
A relevant aspect is the relationship between preterm birth and the presence of fetal and maternal infections. It is estimated that approximately half the spontaneous preterm births are associated with intrauterine infection, which triggers the maternal and fetal inflammatory reaction, leading to the occurrence of uterine contractions and preterm labor [11
]. In addition, the severity of neonatal complications is higher in newborn infants from mothers with intraamniotic infection [12
]. Study carried out in the state of São Paulo established an association between positive cervical cultures and maternal and fetal infectious morbidities, such as urinary tract infections and neonatal infections, especially in cases of preterm [13
]. There are many studies trying to associate infections such as periodontal disease and bacterial vaginosis with preterm labor and prelabor rupture of membranes. However, results are still inconclusive [14
Prelabor rupture of membranes has a close relationship with preterm birth. It is estimated that it is responsible for up to 30% of all preterm births [16
]. Although it frequently occurs at term, when it occurs preterm it mostly results in preterm labor. A hypothesis is that the same infectious mechanisms that cause the loss of membrane integrity are responsible for triggering the inflammatory process that results in uterine contractility. Therefore, according to this interpretation, they would be two clinical manifestations of the same infectious condition [17
Also, there is strong relationship between preterm birth and multiple pregnancies, and prematurity is the main complication in these pregnancies. Among the reasons for this association is the early and exaggerated stretching of myometrial fibers, although extensive researches try to determine the physiopathological mechanism that explains this event, as well as to establish screening tests and preventive measures in order to avoid them [18
Therefore, the probable causes of preterm birth can be divided in three major groups: spontaneous, therapeutic interruption of pregnancy, and prelabor rupture of membranes.
The prevalence of preterm birth in Brazil in 2006 was 6.5% [19
]. However, this number may not be real. Population-based studies demonstrate that it is higher [20
]. The unreal estimate from governmental bodies may be a consequence of difficulties to accurately estimate the gestational age, difficulties in information systems that may result in poor records, therefore decreasing their reliability, and the significant population differences in a continental-sized country. In addition, as in other countries, this prevalence may have increased in the last couple of years, which has not been appropriately emphasized. Late or sometimes nonexistent prenatal care makes it difficult or even impossible to provide a reliable estimate of the gestational age. The same is true regarding the lack of neonatal care during labor, which also contributes to an inaccurate estimate of the gestational age and, consequently, of the incidence of preterm in the country. In addition to easy and appropriate access to prenatal care, it is imperative to develop a national standard to establish the gestational age through the evaluation of the newborn infant, which is essential to implement guidelines in different clinical situations of the obstetrics and pediatrics practices.
In view of all these considerations, we conclude that it is important to assess the situation of preterm birth in Brazil, knowing its real prevalence and associated socioeconomic factors, adopted preventive measures, diagnostic and screening methods applied, interventions, and short term and long term maternal and neonatal results, so that, in association with other developed countries, this evidence will guide health professionals and policy makers in applying the necessary preventive and appropriate measures to face this problem.
The general objective of this study is to evaluate the prevalence of preterm births in several hospitals in Brazil, determining its main causal factors, associated risk factors, treatment protocols, and perinatal morbidity and mortality. Specific objectives are:
1. To know the prevalence of preterm birth in 27 institutions of different Brazilian regions, identifying the methods used to determine the gestational age at birth;
2. To identify and quantify the main causes of preterm birth in these institutions;
3. To identify the diagnostic criteria used by these institutions to identify preterm birth causes;
4. To identify and quantify the main factors associated with preterm birth causes in the different institutions, comparing with term birth;
5. To identify, describe and group the different standards used by these institutions to treat preterm birth causes;
6. To evaluate the preterm birth treatments in these institutions;
7. To determine the early and late neonatal results of preterm births occurred in these institutions.