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

Cirelli, Jessica Fernandes; Surita, Fernanda Garanhani; Costa, Maria Laura; Parpinelli, Mary Angela; Haddad, Samira Maerrawi; Cecatti, José Guilherme

doi:10.1055/s-0038-1623511

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Ginecologia e Obstetrícia

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original Article • Rev. Bras. Ginecol. Obstet. 40 (03) • Mar 2018 • https://doi.org/10.1055/s-0038-1623511 copy

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

A importância das causas indiretas da morbidade e mortalidade maternas no processo de transição obstétrica: um estudo multicêntrico transversal

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

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 independentlyassociatedwithworseresultsintheindirectcausesgroup.Someprocedures 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.

Keywords:
maternal near-miss; maternal death; indirect causes; reproductive health

Total births= 82,838; total live births = 82,144
Cause of SMM n= 9555	Indirect causes n = 942	Direct causes n = 8613
	n (%)	n (%)	PR(95%CI)
SMM
PLTCs	713 (75.7)	7932 (92.1)	Ref.
MNM	170 (18.0)	600 (7.0)	2.74 (2.00–3.74)
MD	59 (6.3)	81 (0.9)	7.56 (4.99–11.45)
Health Indicators
MNMR/1,000 LBs	2.07	7.30
SMOR/1,000 LBs	2.79	8.29
MNM:MD	2.90	7.40
Mortality Index (%)	25.8	11.9
MMR/100,000 LBs	71.8	98.6

Causes of maternal death	n (%)
Influenza H1N1	18 (30.5)
Sepsis	12 (20.3)
Pulmonary	6 (10.1)
Urinary	3 (5.0)
Abdominal	3 (5.0)
Cancer	6 (10.1)
Heart disease	6 (10.1)
AIDS	2 (3.3)
Sickle cell disease	2 (3.3)
Thromboembolic disease	2 (3.3)
Erythematous systemic lupus	1 (1.6)
Bone marrow aplasia	1 (1.6)
Interstitial pneumonia	1 (1.6)
Not identified	8 (13.5)
Total	59 (100)
Previous maternal conditions	Indirect obstetric causes
Previous maternal conditions	SMO n (%)	PLTCs n (%)	PR (95%CI)
Cardiac diseases	14 (6.8)	119 (18.3)	0.40 (0.20–0.81)
Other conditions	33 (16.1)	89 (13.7)	1.15 (0.80–1.66)
Obesity	22 (10.7)	85 (13.1)	0.84 (0.52–1.35)
Smoking	17 (8.3)	54 (8.3)	1.00 (0.72–1.38)
Respiratory diseases	19 (9.3)	45 (6.9)	1.26 (0.73–2.20)
Chronic hypertension	10 (4.9)	46 (7.1)	0.73 (0.42–1.29)
Drug addiction	11 (5.4)	19 (2.9)	1.56 (1.05–2.032)
Sickle cell disease – thalassemia	9 (4.4)	30 (4.6)	0.96 (0.63–1.48)
Diabetes mellitus	8 (3.9)	27 (4.1)	0.95 (0.55–1.64)
Neurologic diseases	3 (1.5)	31 (4.8)	0.36 (0.10–1.32)
HIV-AIDS	9 (4.4)	18 (2.8)	1.41 (0.78–2.54)
Thyroid diseases	6 (2.9)	18 (2.8)	1.05 (0.59–1.84)
Renal diseases	8 (3.9)	13 (2.0)	1.61 (0.65–4.03)
Neoplasia	7 (3.4)	11 (1.7)	1.65 (0.90–3.02)
Collagenoses	4 (1.9)	12 (1.8)	1.04 (0.33–3.29)
Low weight	3 (1.5)	6 (0.9)	1.40 (0.46–4.22)
Total	229	713	806

Sample characteristics	Indirect cause	Direct cause	PR (95%CI)
Sample characteristics	n (%)	n (%)	PR (95%CI)
Age (years)
10–19	172 (18.3)	1,541 (17.9)	0.95 (0.79–1.15)
20–29	480 (51.0)	4,076 (47.3)	Ref.
30–39	256 (27.2)	2,561 (29.7)	0.86 (0.69–1.08)
40–49	34 (3.6)	435 (5.1)	0.69 (0.46–1.03)
Marital status^a
With partner	446 (58.8)	3,827 (52.6)	Ref.
Single	312 (41.2)	3,454 (47.4)	0.79 (0.58–1.09)
Schooling ^b
Primary	277 (45.2)	2,939 (46.6)	0.77 (0.54–1.11)
High school	292 (47.6)	3,020 (47.9)	0.79 (0.54–1.15)
University	44 (7.2)	351 (5.6)	Ref.
Ethnicity ^c
White	386 (51.1)	2,645 (41.4)	Ref.
Non-white	370 (48.9)	3,738 (58.6)	0.71 (0.49–1.03)
Obesity ^d
Yes	107 (12.5)	1,882 (25.5)	0.45 (0.29–0.69)
No	749 (87.5)	5,503 (74.5)	Ref.
Low weight ^d
Yes	9 (1.1)	18 (0.2)	3.23 (1.70–6.14)
No	847 (98.9)	7,367 (99.8)	Ref.
Parity ^e
0	399 (42.6)	4,177 (48.8)	1.17 (0.98–1.38)
1	241 (25.7)	2,129 (24.9)	Ref.
≥ 2	296 (31.6)	2,251 (26.3)	1.14 (0.94–1.38)
Abortions ^f
0	709 (75.7)	6,659 (77.8)	Ref.
≥ 1	227 (24.3)	1,896 (22.2)	1.11 (0.93–1.32)
Perinatal outcomes	Indirect cause	Direct cause	PR (95%CI)
Perinatal outcomes	n (%)	n (%)
End of pregnancy^h
Vaginal birth	128 (13.8)	2,010 (23.4)	Ref.
Cesarean section	394 (42.4)	5,760 (67.1)	1.07 (0.76–1.50)
Abortion	56 (6.0)	489 (5.7)	1.72 (1.11–2.64)
**Still pregnant	351 (37.8)	326 (3.8)	7.93 (6.04–10.41)
Gestational age at delivery (weeks)ⁱ
< 28	57 (6.5)	552 (6.8)	1.49 (1.16–1.91)
28–33	88 (10.0)	1,336 (16.4)	0.98 (0.67–1.44)
34–36	98 (11.2)	1,682 (20.7)	0.88 (0.63–1.23)
> 37	284 (32.3)	4,238 (52.1)	Ref.
Low birthweight (g)^j
< 2,500	171 (35.8)	2,978 (40.0)	0.85 (0.66–1.09)
≥ 2,500	306 (64.2)	4,468 (60.0)	Ref.
Apgar Score at 5 minutes
< 7	26 (5.7)	270 (3.8)	1.49 (1.01–2.21)
≥7	431 (94.3)	6,898 (96.2)	Ref.
Vital condition at birth^k
Alive	474 (95.0)	7,259 (95.2)	Ref.
Stillbirth	25 (5.0)	363 (4.8)	1.05 (0.69–1.61)
Neonatal outcome^l
Discharged	365 (78.2)	5,258 (75.3)	Ref.
Transferred	88 (18.8)	1,542 (22.1)	0.83 (0.64–1.08)
Neonatal death	14 (3.0)	179 (2.6)	1.12 (0.72–1.74)
Health care^m
Public	918 (97.8)	8,522 (99.0)	Ref.
Other	21 (2.2)	85 (1.0)	2.04 (1.35–3.08)

Variables	PR	95%CI	p
Other preexisting conditions	2.48	1.91–3.21	< 0.001
Cause (exclusively indirect)	2.61	1.77–3.86	< 0.001
Financial coverage for hospitalization (other)	2.52	1.70–3.74	< 0.001
Obesity	0.58	0.45–0.75	< 0.001
Schooling (high school or higher)	0.68	0.57–0.82	< 0.001
Gestational age during the outcome (weeks)	0.96	0.94–0.98	< 0.002
Marital status (no partner)	0.52	0.35–0.77	0.002
Diabetes	1.90	1.24–2.90	0.005
Neoplasia	1.98	1.25–3.14	0.005
Kidney diseases	1.99	1.14–3.49	0.018
Sickle cell anemia	2.50	1.16–5.41	0.022
Drug addiction	1.98	1.03–3.80	0.042

Federação Brasileira das Sociedades de Ginecologia e Obstetrícia Av. Brigadeiro Luís Antônio, 3421, sala 903 - Jardim Paulista, 01401-001 São Paulo SP - Brasil, Tel. (55 11) 5573-4919 - Rio de Janeiro - RJ - Brazil
E-mail: editorial.office@febrasgo.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Address for correspondence Fernanda Garanhani Surita, Rua Alexander Fleming 101, 13083-881, Campinas, SP, Brazil (e-mail: surita@unicamp.br).