The Burden of Indirect Causes of Maternal Morbidity and Mortality in the Process of Obstetric Transition: A Cross-Sectional Multicenter Study

Abstract

A importância das causas indiretas da morbidade e mortalidade maternas no processo de transição obstétrica: um estudo multicêntrico transversal AbstractObjective The aim of this study is to evaluate the burden of indirect causes of maternal morbidity/mortality in Brazil. Methods Secondary analysis of a multicenter cross-sectional study conducted in 27 referral obstetric units within the Brazilian Network for Surveillance of Severe Maternal Morbidity. Results A total of 82,388 women were surveilled: 9,555 women with severe maternal morbidity were included, and 942 (9.9%) of them had indirect causes of morbidity/ mortality. There was an increased risk of higher severity among the indirect causes group, which presented 7.56 times increased risk of maternal death (prevalence ratio [PR]: 7.56; 95% confidence interval [95%CI]: 4.99-11.45). The main indirect causes of maternal death were H1N1 influenza, sepsis, cancer and cardiovascular disease. Non-public antenatal care (PR: 2.52; 95%CI: 1.70-3.74), diabetes (PR: 1.90; 95%CI: 1.24-2.90), neoplasia (PR: 1.98; 95%CI: 1.25-3.14), kidney diseases (PR: 1.99; 95%CI: 1.14-3.49), sickle cell anemia (PR: 2.50; 95%CI: 1.16-5.41) and drug addiction (PR: 1.98; 95%CI: 1.03-3.80) were independently associated with worse results in the indirect causes group. Some procedures for the management of severity were more common for the indirect causes group. Conclusion Indirect causes were present in less than 10% of the overall cases, but they represented over 40% of maternal deaths in the current study. Indirect causes of maternal morbidity/mortality were also responsible for an increased risk of higher severity, and they were associated with worse maternal and perinatal outcomes. In middle-income countries there is a mix of indirect causes of maternal morbidity/ mortality that points to some advances in the scale of obstetric transition, but also reveals the fragility of health systems.

Mortality in pregnancy and the postpartum period in women with severe acute respiratory distress syndrome related to COVID‐19 in Brazil, 2020

“…Black women had the worst mortality rate (13.6%), which was twice as high as white women (6.7%). The pandemic pattern of COVID‐19 highlights the deficiencies in obstetric care and social inequities in access to health care 2 …”

“…At the beginning of the pandemic, a major concern among clinicians was whether pregnant women would represent a group at risk for serious outcomes, as previously seen for acute respiratory distress syndrome (ARDS) caused by the influenza virus. 1,2 New scientific information is continuously being collected. In July 2020, Takemoto et al 3 reported 124 deaths of pregnant or postpartum women with ARDS caused by COVID-19 in 978 Brazilian women.…”

Adverse obstetric outcomes in two Brazilian maternity hospitals

“…While data on AO frequency in hospitalized patients (7.6% of patients, 66.7% avoidable AOs) exist, there are none on childbirth care (Mendes et al , 2009). Other studies have investigated the indicators of classic morbidity and mortality or maternal and neonatal near misses, but these conditions are less frequent than obstetric AOs (Cirelli et al , 2018; Silva et al , 2018). Knowing these data might be an essential step in promoting patient safety practices which help improve healthcare quality, and constitute a priority of the World Health Organization (WHO) in attempt to meet the Sustainable Development Goals by 2030 (Kieny et al , 2018).…”

Temporal trends of maternal near miss in Brazil between 2000 and 2012

“…3 The highest maternal near miss rates are reported in developing countries 4 and the causes related to maternal near miss in these countries are similar to those of maternal mortality. 2,5 A number of factors that are determinants of mortality are also relevant for morbidity, such as the lack of adequate access to prenatal and childbirth, in addition to the absence of specific technological support, such as an intensive therapy unit or even emergencial blood transfusions. 6 The increase in maternal morbidity rates, especially in low-income countries, demonstrates the inability of the health services to offer quality in maternal care.…”