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

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.

Keywords

maternal near-miss - maternal death - indirect causes - reproductive health

Palavras-chave

near-miss materno - morte materna - causas indiretas - saúde reprodutiva

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.

• References

• 1 Cecatti JG, Costa ML, Haddad SM. , et al; Brazilian Network for Surveillance of Severe Maternal Morbidity Study Group. Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care. BJOG 2016; 123 (06) 946-953
• 2 World Health Organization. Brazil: Who Statistical Profile . Geneva: WHO; 2015. http://www.who.int/gho/countries/bra.pdf . Accessed December 14, 2016
• 3 Say L, Souza JP, Pattinson RC. ; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss–towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23 (03) 287-296
• 4 Cochet L, Pattinson RC, Macdonald AP. Severe acute maternal morbidity and maternal death audit--a rapid diagnostic tool for evaluating maternal care. S Afr Med J 2003; 93 (09) 700-702
• 5 Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367 (9516): 1066-1074
• 6 Say L, Chou D, Gemmill A. , et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2 (06) e323-e333
• 7 Lumbiganon P, Laopaiboon M, Intarut N. , et al; WHO Multicountry Survey on Maternal and Newborn Health Research Network. Indirect causes of severe adverse maternal outcomes: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 121 (Suppl. 01) 32-39
• 8 Souza JP, Tunçalp Ö, Vogel JP. , et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 2014; 121 (Suppl. 01) 1-4
• 9 Haddad SM, Cecatti JG, Parpinelli MA. , et al; National Network for the Surveillance of Severe Maternal Morbidity Group. From planning to practice: building the national network for the Surveillance of Severe Maternal Morbidity. BMC Public Health 2011; 11: 283
• 10 Haddad SM, Sousa MH, Cecatti JG, Parpinelli MA, Costa ML, Souza JP. ; Brazilian Network for Surveillance of Severe Maternal Morbidity Group. Intraclass correlation coefficients in the Brazilian network for Surveillance of Severe Maternal Morbidity study. BMC Pregnancy Childbirth 2012; 12: 101
• 11 Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001; 322 (7294): 1089-1093 , discussion 1093–1094
• 12 Murthy BK, Murthy MB, Prabhu PM. Maternal mortality in a tertiary care hospital: a 10-year review. Int J Prev Med 2013; 4 (01) 105-109
• 13 Lee QY, Odoi AT, Opare-Addo H, Dassah ET. Maternal mortality in Ghana: a hospital-based review. Acta Obstet Gynecol Scand 2012; 91 (01) 87-92
• 14 Abouchadi S, Belghiti Alaoui A, Meski FZ, De Brouwere V. Implementing a maternal mortality surveillance system in Morocco - challenges and opportunities. Trop Med Int Health 2013; 18 (03) 357-365
• 15 Cristina Rossi A, Mullin P. The etiology of maternal mortality in developed countries: a systematic review of literature. Arch Gynecol Obstet 2012; 285 (06) 1499-1503
• 16 Pfitscher LC, Cecatti JG, Haddad SM. , et al; Brazilian Network for Surveillance of Severe Maternal Morbidity Study Group. The role of infection and sepsis in the Brazilian Network for Surveillance of Severe Maternal Morbidity. Trop Med Int Health 2016; 21 (02) 183-193
• 17 Creanga AA, Johnson TF, Graitcer SB. , et al. Severity of 2009 pandemic influenza A (H1N1) virus infection in pregnant women. Obstet Gynecol 2010; 115 (04) 717-726
• 18 Dellinger RP, Levy MM, Rhodes A. , et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41 (02) 580-637
• 19 Singer M, Deutschman CS, Seymour CW. , et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315 (08) 801-810
• 20 Bray F. Transitions in human development and the global cancer burden. In: Stewart BW, Wild CP. , eds. World Cancer Report 2014 . Lyon: International Agency for Research on Cancer; 2014: 54-58
• 21 Regitz-Zagrosek V, Gohlke-Bärwolf C, Geibel-Zehender A. , et al. [Heart diseases in pregnancy]. Clin Res Cardiol 2008; 97 (09) 630-665
• 22 Regitz-Zagrosek V, Seeland U, Geibel-Zehender A, Gohlke-Bärwolf C, Kruck I, Schaefer C. Cardiovascular diseases in pregnancy. Dtsch Arztebl Int 2011; 108 (16) 267-273
• 23 Souza JP. [Maternal mortality and development: the obstetric transition in Brazil]. Rev Bras Ginecol Obstet 2013; 35 (12) 533-535