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DOI: 10.1055/s-0038-1623511
The Burden of Indirect Causes of Maternal Morbidity and Mortality in the Process of 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 transversalPublication History
27 June 2017
13 December 2017
Publication Date:
02 April 2018 (online)
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 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.
Resumo
Objetivo O objetivo deste estudo é avaliar a importância das causas indiretas da morbidade/mortalidade materna no Brasil.
Métodos Análise secundária de um estudo transversal multicêntrico realizado em 27 unidades obstétricas de referência da Rede Brasileira de Vigilância da Morbidade Materna Grave.
Resultados Um total de 82.388 mulheres foram avaliadas, sendo que 9.555 foram incluídas com morbidade materna grave, 942 (9,9%) delas com causas indiretas de morbidade/mortalidade. Houve risco aumentado de maior gravidade entre o grupo das causas indiretas, que apresentou risco de morte materna 7,56 vezes maior (razão de prevalência [RP]: 7.56; intervalo de confiança de 95% [IC95%]: 4.99–11.45). As principais causas indiretas de óbitos maternos foram a gripe H1N1, sepses, câncer e doença cardiovascular. Atenção pré-natal não pública (RP: 2,52; IC95%: 1,70–3,74), diabetes (RP: 1,90; IC95%: 1,24–2,90), neoplasia (RP: 1,98; IC95%: 1,25–3,14), doenças Renais (RP: 1,99; IC95%: 1,14–3,49), anemia falciforme (RP: 2,50; IC95%: 1,16–5,41) e toxicodependência (PR 1,98; IC95%: 1,03–3,80) foram associados independentemente com piores resultados no grupo de causas indiretas. Alguns procedimentos para o manejo da gravidade foram mais comuns para o grupo de causas indiretas.
Conclusão As causas indiretas de morbidade mortalidade materna ocorreram em menos de 10% dos casos, mas foram responsáveis por mais de 40% das mortes maternas no presente estudo. As causas indiretas da morbidade mortalidade materna também se relacionaram com maior gravidade, e estiveram associadas a piores resultados maternos e perinatais. Nos países de renda média, há uma combinação de causas indiretas de morbidade/mortalidade materna que apontam para alguns avanços na escala de transição obstétrica, mas também mostram a fragilidade dos sistemas de saúde.
Contributors
The idea for the study and this specific analytical approach arose in a group discussion among all the authors. The analyses were planned by Cirelli JF, Surita FG and Cecatti JG. The first version of the manuscript was drafted by Cirelli JF, Surita FG and Costa ML. Subsequently, all remaining authors complemented it with suggestions. All authors contributed to the development of the study protocol and approved the final version of the manuscript.
