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Multicenter Study
. 2018 Mar;40(3):106-114.
doi: 10.1055/s-0038-1623511. Epub 2018 Apr 2.

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

Jessica Fernandes Cirelli  1 , Fernanda Garanhani Surita  1 , Maria Laura Costa  1 , Mary Angela Parpinelli  1 , Samira Maerrawi Haddad  1 , José Guilherme Cecatti  1
Affiliations
Multicenter Study

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

Jessica Fernandes Cirelli et al. Rev Bras Ginecol Obstet. 2018 Mar.

Abstract
in English, Portuguese

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.

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.

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Conflict of interest statement

The authors have no conflicts of interest to disclose.

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