Mate rnal mortality in Campinas:
Evolution, unde r-re gistration and avoidanc
Obstetrics unit, Department of Gynecology and Obstetrics, School of Medical Sciences,
Universidade Estadual de Campinas, Campinas, Brazil.
INTRODUCTION
Up until a few years ag o , maternal mo rtality did no t merit much attentio n as a wo rldwide public health issue. The health and so cial develo pment indic a to r a lmo st e xc lusive ly use d wa s infa nt death.1 Internatio nally, co ncern abo ut the pro blem o f MM o nly beg an to materialize in the mid 8 0 s, when the W o rld Health O rg anizatio n launched its “ Safe Mo therho o d Initiative” ,2 and it made its mark at the Internatio nal Co nference o n Safe Mo therho o d in N airo bi, Kenya, in 1 9 8 7 .3
In the case o f Brazil, the first impo rtant step was taken with the o rg anizatio n o f a natio nal meeting o n the theme in 1 9 8 4 , in the city o f São Paulo . A gro up o f researchers fro m the Scho o l o f Public Health of the University of São Paulo, directed by Laurenti, also had an impo rtant ro le in its study here. Ho wever, the first o fficial initiative o nly appeared in 1 9 8 7 , when the São Paulo State Secretariat o f Health launched its Pro g ram fo r Maternal Death Preventio n which, amo ng o ther me a sure s, c re a te d se ve n ma te rna l mo rta lity co mmittees in impo rtant regio ns o f the state, the first o nes to functio n in this co untry.4 Later o n, this interest spread thro ugho ut Brazil, being o fficially accepted as a public health problem by the Ministry o f Health, which started to make effo rts to stimulate
José Guilherme Cecatti Aníbal Faúndes Fernanda Garanhani de Castro Surita
Original Article
REVISTA PA ULISTA DE M EDIC IN A
Medical Journal
S ã o Pa u l oABSTRACT
Contex t: Up until a few years ag o , maternal mo rtality did no t merit much attentio n as a wo rldwide public health issue. The health and so cial develo pment indicato r almo st exclusively used was infant death.
O bjective: To study the number, characteristics, basic
causes and avo idance o f maternal mo rtality (MM) amo ng wo men living in the city o f Campinas, which o ccurred between 1 9 8 5 and 1 9 9 1 , identified fro m all death certificates o f wo men ag ed 1 0 thro ug h 4 9 years.
Design: Retro spective and descriptive po pulatio n-based
study.
Setting: University Referal Center.
Sa m ples: All elig ible death certificates classified as declared and presumed maternal deaths acco rding to the Laurenti criteria fo r the cause o f death were selected and co mplementary studies o f the clinical reco rds were perfo rmed.
M a in m ea sures: Day o f the week and place o f o ccurrence
o f death; perio d o f o ccurrence; transfer fro m ano ther ho spital; number o f days fro m delivery/ abo rtio n to death; blo o d transfusio n; o ppo rtunity fo r transfusio n; co mplicatio ns; auto psy; basic cause o f death.
Results: Initially 3 9 declared maternal deaths were identified and a to tal o f 6 2 were co nfirmed by the end o f the study. This co rrespo nds to an under-reg istratio n rate o f 3 7 .1 % and to an MM ratio o f 4 5 .5 per 1 0 0 ,0 0 0 live births. Aro und three-fo urths o f these maternal deaths were due to a direct o bstetrical cause and were co nsidered avo idable.
Conclusion: Maternal mo rtality still is hig h in the municipality o f Campinas, altho ug h lo wer than the mean estimated fo r Braz il. The predo minance o f direct o bstetric causes and avo idable deaths reinfo rces the need fo r public health interventio ns directed to wards avo iding them.
Key w ords: Maternal Death. Repro ductive Health.
its p ro mo tio n thro ug ho ut the na tio n.5 The achievements o btained thro ugh the implementatio n o f the pro gram fo r preventio n o f maternal deaths in Paraná, currently the state where this pro gram is best develo ped, deserve to be reco gnized.6 ,7
Maternal mo rtality in Brazil is quite hig h, especially when co mpared to that o f develo ped co untries. Ho wever, the acquisitio n o f reliable data is a hard task. O fficial statistics are far fro m reflecting the real situatio n in the co untry.5 ,8 ,9 A study carried o ut in the Municipality o f Campinas sho wed that, o ver a perio d o f 5 years (1 9 7 9 -1 9 8 3 ), o nly 4 0 .4 % o f ma terna l dea ths were reg istered a t the reg istry o ffice, a nd fo und a Maternal Mortality Ratio (MMR) of 5 7 per 1 0 0 ,0 0 0 live births (LB).1 0
Co rrelatio n o f regio nal data o btained fro m death certificates with lo cal, carefully registered detailed info rmatio n clearly sho ws the unreality o f the o fficial data. A carelessness can be o bserved in this co untry regarding the filling o ut o f death certificates, which o ught to be a so urce o f co rrect info rmatio n. A tendency to wards attributing a specific o rganic cause to a maternal death, witho ut c o nsid e ring the mo me nt in the w o ma n’ s repro ductive life, can be no ted.1 1 ,1 2 ,1 3
This hampers the use o f this so urce o f death info rmatio n in o btaining a faithful scenario o f maternal mo rtality in the co untry. Ho wever the p ro b le m is no t e xc lusive to Bra z il no r to underdevelo pment. Develo ped co untries with
well-structured health systems, such as the United States o f America and France, face similar situatio ns, with percentag es o f o fficial reg istratio n o f maternal de a ths va rying fro m 4 6 to 8 5 % o f the re a l numbers.1 0 ,1 4 ,1 5 ,1 6
Thus, in a general way, maternal mo rtality is little kno wn in o ur co untry. The majo rity o f the data a va ila b le is b a sed o n sta tistic s fro m ho spita l institutions, or even from cities, that normally receive a larg e number o f wo men referred fro m o ther places, with pregnancy, delivery and po st-partum co mplicatio ns, greatly increasing the number o f deaths registered there. O n the o ther hand, it is supposed that official statistics based on the analysis o f death certificates are under-registered.
In spite o f these difficulties, the info rmatio n available allo ws us to affirm that maternal mo rtality is still to o high when co mpared to that o f develo ped co untries, and the highest percentage o f maternal deaths are due to direct causes, and therefo re avo idable in the majo rity o f cases.1 2 ,1 7
In the specific case of Campinas city, whose tertiary level hospital network functions as the referral center for all the region, maternal deaths among women residing in neighboring cities or districts are very frequent. Co nsequently, the o ccurrence o f the event in Campinas itself is artificially increased.
The need to kno w the real mag nitude o f maternal mortality over recent years among women living o nly in this city, the characteristics o f these deaths and the quality o f their registratio n, as well
Ta ble 1 - Identifica tion a nd under-registra tion of ma terna l dea ths in the municipa lity of Ca mpina s during the period from 1 9 8 5 to 1 9 9 1 .
Deaths o f Maternal Deaths % o f
Year W o men Declared Presumable Identified To tal o f
Under-1 0 -4 9 in the study Co nfirmed reg istratio n
1 9 8 5 2 7 5 9 2 8 2 1 1 1 8 .2
1 9 8 6 2 4 8 6 3 1 3 9 3 3 .3
1 9 8 7 2 9 7 3 3 7 3 6 5 0 .0
1 9 8 8 3 1 5 6 2 6 6 1 2 5 0 .0
1 9 8 9 2 8 4 5 1 8 2 7 2 8 .6
1 9 9 0 3 3 2 6 2 8 1 7 1 4 .3
1 9 9 1 3 1 1 4 3 6 6 1 0 6 0 .0
as the non-existence of consistent official data, justify this study. The results o btained will allo w a mo re realistic diagno sis o f the state o f maternal mo rtality in this perio d, besides making it po ssible to direct health actio ns and interventio ns in o rder to reduce mo rtalities.
The purpo se o f this study was to evaluate the number and the characteristics o f maternal d e a ths a mo ng w o me n living in the c ity o f Campinas during the perio d fro m 1 9 8 5 to 1 9 9 1 , identified amo ng all death certificates o f wo men ag ed between 1 0 thro ug h 4 9 years o ld, after co mplementary investig atio n. The study was also aimed at determining the percentag e o f under reg istratio n o f maternal mo rtality, its causes and avo idance.
METHODS
Maternal deaths amo ng wo men living in the city o f Campinas o ccurring in the perio d fro m January 1 9 8 5 to December 1 9 9 1 were studied. The intentio n was to try to identify these deaths starting fro m a systematic analysis o f all death certificates of women aged between 1 0 to 4 9 years in this city, and then to perfo rm a mo re detailed study o f each case. Initially, co pies o f all death c e rtific a te s w e re o b ta ine d fro m the SEA DE Fo undatio n (State Data Analysis System) o f São Pa ulo Sta te . The c e rtific a te s we re se pa ra te d acco rding to the ho spital where the death had
o ccurred. The clinical directo r o r administrato r o f each hospital was contacted to obtain authorization fo r access to the clinical reco rds and labo rato ry data o f each case.
The death certificates were divided into three g ro ups: de c la re d ma te rna l de a th, pre sume d ma te rna l d e a th, a nd d e a th no t re la te d to pregnancy, delivery o r puerperium. The criteria pro po sed by Laurenti were used fo r differentiating cases into these three g ro ups.9 The metho d o f screening each case fo r a maternal cause was the same as reco mmended by the São Paulo State Secretariat o f Health fo r the maternal mo rtality co mmittees.
An in-depth analysis o f cases classified as declared o r presumed maternal deaths was carried o ut, regarding the co nditio ns leading to death, via d e ta ile d o b se rva tio n o f c linic a l re c o rd s, c o mp le me nta ry la b o ra to ry te sts, a d d itio na l info rmatio n pro vided by ho spital perso nnel, and auto psy when available. A special fo rm was filled o ut fo r each case co nfirmed as maternal death, which co nstituted the data base fo r this study.
O nly deaths fro m a declared maternal cause o r a presumed o ne which was later co nfirmed were included in this study. Cases o f co nfirmed maternal death with inco mplete info rmatio n, fo r instance when the clinical reco rd had been lo st, were also included. In these cases so me o f the info rmatio n had to be co nsidered as unkno wn.
The main variables studied were: day o f the
Ta ble 2 - Estima te of officia l a nd confirmed ma terna l morta lity ra tios for the municipa lity of Ca mpina s during the period from 1 9 8 5 to 1 9 9 1
Declared Co nfirmed N umber o f O fficial Co nfirmed
Year Maternal Maternal Live MMR/ MMR/
Deaths Deaths Births* 1 0 0 ,0 0 0 LB 1 0 0 ,0 0 0 LB
1 9 8 5 9 1 1 1 7 ,5 8 7 5 1 .2 6 2 .5
1 9 8 6 6 9 1 7 ,9 7 5 3 3 .4 5 0 .1
1 9 8 7 3 6 1 9 ,5 9 1 1 5 .3 3 0 .6
1 9 8 8 6 1 2 2 0 ,0 2 2 2 9 .9 5 9 .9
1 9 8 9 5 7 2 0 ,7 1 9 2 4 .1 3 3 .8
1 9 9 0 6 7 2 0 ,0 9 8 2 9 .8 3 4 .8
1 9 9 1 4 1 0 2 0 ,4 0 5 1 9 .6 4 9 .0
TO TAL 3 9 6 2 1 3 6 ,3 9 7 2 8 .6 4 5 .5
week and place o f o ccurrence o f death (ho spital, transpo rtatio n, ho me, public places); perio d o f occurrence (pregnancy, labor, post-partum); transfer fro m a no the r ho spita l; numb e r o f da ys fro m delivery/ abo rtio n to death; blo o d transfusio n; o p p o rtunity fo r tra nsfusio n; c o mp lic a tio ns (hemo rrhag e, po st-partum infectio n; co nvulsio n, no ne); auto psy; and basic cause o f death after inve stig a tio n a c c o rd ing to the Inte rna tio na l Classificatio n o f Diseases (ICD, 9 th revisio n), i.e. direct obstetric deaths (pregnancy specific diseases: ICD 6 3 0 to 6 7 9 ), indirect o bstetric deaths (no n-preg nancy specific diseases but wo rsened by pregnancy: ICD 2 2 2 ) and deaths fro m unkno wn basic causes (ICD 9 9 9 ). The W HO definitio n o f maternal death, with an extension of the post-partum perio d to o ne year, was ado pted.1 8 The avo idance o f a death was defined based o n the detailed analysis o f each case and co nsidering whether any interventio n co uld have been taken to prevent the death, at any time during pregnancy, labo r o r po st-partum, either by the wo man herself, the physician o r the health system. Deaths derived fro m unwanted o r co ntraindicated preg nancies, that o c c urred a s a result o f la c k o f c o ntra c eptive info rma tio n o r a c c e ss to se rvic e s w e re a lso included.
Statistical Metho ds. All data was input into a co mputer file fo r later tabulatio n and analysis. The desc riptive a na lysis o f a ll ma terna l dea ths identified is presented in this pa per in the fo rm o f perc enta g e distrib utio n a nd mea n, with its
sta nda rd devia tio n in the c a se o f q ua ntita tive va ria b les.
RESULTS
A to ta l o f 2 0 6 2 dea th c ertific a tes were identified as co rrespo nding to wo men aged 1 0 thro ugh 4 9 , living in Campinas, who died during the perio d. Thirty-nine o f these were declared as maternal deaths, and 2 0 4 were classified as p re sume d ma te rna l d e a ths, c o rre sp o nd ing respectively to 1 .9 and 9 .9 % o f all certificates reviewed. After the systematic analysis o f clinical reco rds, 2 3 o f the presumed maternal deaths and all o f the declared o nes were co nfirmed, giving a to tal o f 6 2 co nfirmed maternal deaths. This means that during the study perio d there was an under-registratio n o f maternal deaths o f 3 7 .1 % in the o fficial statistics based o n the data fro m death certificates. Co mparing this rate year by year o ver the perio d, no trend in impro ving o r wo rsening o f the under-repo rting was o bserved (Table 1 ).
Co nsidering that there were 1 3 6 ,3 9 7 live b irths in C a mpina s during the sa me pe rio d, a c c o rd ing to d a ta p ro vid e d b y the SEA DE Fo und a tio n, the “ o ffic ia l” MMR w a s 2 8 . 6 / 1 0 0 ,0 0 0 LB including o nly declared maternal deaths. Adding the presumed maternal deaths that were co nfirmed, an MMR o f 4 5 .5 / 1 0 0 ,0 0 0 LB was reached. The greatest MMR was o bserved in 1 9 8 5 , with 6 2 .5 , and the lo west, o f 3 0 .6 in 1 9 8 7 (Table 2 ). There were 3 8 confirmed maternal deaths and 7 5 ,1 7 5 LB during the first four years from 1 9 8 5 thro ugh 1 9 8 8 , with a MMR o f 5 0 .5 . In the last three years o f the study (1 9 8 9 -1 9 9 1 ) there were 2 4 maternal deaths and 6 1 ,2 2 2 LB, with an MMR of 39.2, showing an apparent decrease in maternal mo rtality o f 2 2 % during the perio d.
The me a n a g e o f the wo me n who ha d maternal death was 2 7 .2 years (± 6 .0 ) and the mean number of years of schooling was 5 .4 years (± 3 .3 ). Approximately three-quarters of them lived in a stable union with a partner and did not have paid work. The mean parity was 1.5 (± 1.9) children. About 9 0 % of these women had had prenatal care and almost 60% had had public sector medical care. O nly one third had a vaginal delivery.
Ta ble 3 - Distribution of ma terna l dea ths a ccording to the da y of the w eek w hen dea th occurred,
Ca mpina s, 1 9 8 5 -1 9 9 1
DAY N %
Sunday 5 8 .1
Mo nday 9 1 4 .5
Tuesday 9 1 4 .5
W ednesday 1 1 1 7 .7
Thursday 8 1 2 .9
Friday 9 1 4 .5
Saturday 1 1 1 7 .7
O nly 8 % of the maternal deaths occurred on Sundays, about half as many as on Saturdays and Wednesdays (18%) (Table 3). All the maternal deaths occurred in a hospital, but at least 1 4 .5 % of cases had been transferred from one hospital to another. Death o ccurred during pregnancy (befo re abo rtio n o r delivery) in o nly five wo men (8 %). Amo ng the o ther maternal deaths, the number o f days fro m o utco me o f pregnancy to death varied fro m 0 thro ugh 6 3 , with an average o f 7 .4 days. O nly two wo men died after the 4 2 nd day po st-partum perio d o riginally defined by W HO . O nly 1 5 wo men (2 4 %) had an auto psy fo r the purpo se o f co nfirming the cause o f death.
The classification of causes of maternal deaths sho wed a co mplete predo minance (8 1 %) o f direct o bstetric causes (Table 4 ). The mo st frequent basic cause o f death identified was hypertensio n (3 1 %), fo llo wed by po st-partum hemo rrhage with 1 5 %. It is also interesting to no tice that o nly 3 % o f deaths were due to an abo rtio n.
M a te rna l d e a ths w e re c o nsid e re d a s avo idable in three-quarters o f the cases (Table 5 ). The respo nsibility fo r the avo idable deaths lay mo stly with the ho spital and physician care. Blo o d transfusio n was carried o ut in almo st half o f the wo men who died (fo r who m the info rmatio n was available), and in 1 4 % o f them it was perfo rmed later than required. Finally, five o f the wo men (8 %) had been discharged fro m the ho spital fro m so me time after the o utco me o f pregnancy until the o nset o f co mplicatio ns that led to death.
DISCUSSION
This study co nfirms ho w difficult it is to o btain reliable data o n the number o f maternal deaths. Ha ving ma na g e d to ide ntify virtua lly a ll the maternal deaths during a perio d o f seven years in the city o f Campinas, the co nfirmed MMR o f 4 5 .5 / 1 0 0 ,0 0 0 LB seems relatively lo w, in the co ntext o f the present situatio n o f maternal health in Brazil.
Twenty-three out of the 6 2 confirmed maternal deaths were identified o nly after review o f the medical reco rds and o ther clinical info rmatio n. This co rrespo nds to an under-registratio n o f 3 7 .1 % o f the maternal deaths in the o fficial statistics. In o ther
wo rds, mo re than o ne in every three maternal deaths did no t appear in the o fficial statistics, if it is co nsidered that o ur pro cedures were efficient eno ugh to identify all o r almo st all maternal deaths. In this sense it sho uld be co nsidered that the “confirmed” MMR does not necessarily mean “real” MMR, as it is impo ssible to be sure that all maternal deaths were identified. It is clear, ho wever, that o fficial statistics o n maternal deaths co ntinued to be unreliable during the perio d o f the study.
Altho ugh in Brazil data o n maternal deaths is not systematically collected by an epidemiological surveillance system fo r ro utine statistics, it is evident that the MMR estimated by the Brazilian Ministry o f Health, o r by the SEADE Fo undatio n fo r São Paulo , based o n causes stated o n death certificates, gives a general picture well belo w the reality, when co mpared with studies that used the same metho d as described in this paper.8 ,1 0 ,1 9 O n the o ther hand, if the c o rre c tio n fa c to r re c o mme nd e d fo r so utheastern Brazil by the Ministry o f Health were applied to the Campinas data 5, the results wo uld be an o verestimate o f the MMR in this specific case. Thus, the MMR corresponding to the “declared” maternal deaths in Campinas, of 28.6/ 100,000 LB, could be wrongly interpreted as being very close to
Ta ble 4 - Distribution of ma terna l dea ths a ccording to the identified ba sic ca use of dea th
a nd its cla ssifica tion, Ca mpina s, 1 9 8 5 -1 9 9 1
BASIC CAUSE n %
Direct o bstetric 5 0 8 1
Abo rtio n 2 3
Ecto pic preg nancy 2 3
Hemo rrhag e 5 8
Hypertensio n 1 9 3 1
O ther preg nancy co mplicatio n 4 6
Placental and fetal pro blem 1 2
Po st-partum hemo rrhag e 9 1 5
Puerperal infectio n 6 1 0
O ther puerperal co mplicatio n 1 2
Placental retentio n 1 2
Indirect o bstetric 1 1 1 8
Ig no red 1 2
the ratio for developed countries. It is obvious that such wro ng interpretatio n o f data wo uld have implications for the strategies to be adopted and the interventions to be implemented for improving the maternal health status of this population.
Ano ther po int to be co nsidered is a po ssible te mp o ra l tre nd re g a rd ing the o c c urre nc e o f maternal deaths, as the study includes a perio d o f seven years. The “ co nfirmed” MMR fo r each year varied fro m 3 0 .6 in 1 9 8 7 to 6 2 .5 / 1 0 0 ,0 0 0 LB in 1 9 8 5 . Co nsidering the retro spective character o f this study, it sho uld be taken into acco unt that, the further away in time an event is, the mo re difficult it is to o btain info rmatio n o n it.
This, ho wever, wo uld be co nco rdant with obtaining sequentially greater MMRs, which was not observed, allowing us to suspect there may be so me tre nd to wa rds re duc tio n in the MMRs. Contributing to this hypothesis, comparison with the “confirmed” MMR of 5 7 / 1 0 0 ,0 0 0 LB in Campinas for the period 1 9 7 9 -1 9 8 3 , which is close to the MMR o f 1 9 8 5 in this study, sho ws that it is mo re than 1 0 points higher than the levels for the period 1 9 8 5 -1 9 9 1 .1 0 This idea is also reinforced by the fact that the MMR of 5 0 .5 / 1 0 0 ,0 0 0 LB for the first part o f this study perio d, fro m 1 9 8 5 to 1 9 8 8 , changed to 3 9 .2 / 1 0 0 ,0 0 0 LB in the second part o f the perio d, fro m 1 9 8 9 to 1 9 9 1 .
Perhaps it wo uld also be impo rtant to bear in mind that reg ular activities o f the Maternal Mo rtality Co mmittee o f Campinas started in 1 9 8 8 . In spite o f disco ntinuities and pro blems with its functio ning , it is pro bable that the co ncept o f maternal death began to be mo re disseminated,
discussed and kno wn in the regio n fro m that time. This co uld be a partial explanatio n fo r the apparent uniformity or stabilization of the number of maternal deaths identified fro m 1 9 8 9 o nwards, at a level apparently inferio r to that o bserved in 1 9 8 5 -1 9 8 6 .
A ltho ug h the ho sp ita ls w e re g e ne ra lly extremely cooperative in giving access to their clinical files, there were access difficulties with institutions lo c a ted o utside the c ity a nd tho se no lo ng er operating. Even finding the clinical records did not always signify access to the information needed. The state of some institutions regarding the quality of their records and files is lamentable. W ith few exceptions, the doctor does not log down the clinical histo ry, anamnesis, daily evo lutio n, co mments, diagnostic hypotheses or therapeutic propositions in the clinical record. O ften the only available data was from the death certificate and administrative records filled for hospitalization or financial purposes. Another problem that could alter the results is the fact that the doctor, facing a serious clinical status and without knowing the case well, has a natural tendency to associate the death to the immediate causes and not to the basic one. W hen the death occurs within a period of 24 hours from the beginning of clinical care, the death certificate should be issued by the Institute of Legal Medicine or by the Death Verification Service. In the first situation the problem of the identification of maternal death is practically solved. In the second, however, the only available data is what is written on the death certificate, which does not allow complete elucidation of the cause of death.
Re g a rd ing the c irc umsta nc e s a nd characteristics of the deaths, initially it was thought that there was a relationship between the day of the week and the occurrence of the maternal death, based on the supposition that there may be greater difficulties in obtaining appropriate care for serious cases that evolved to death during weekends. The relatively small number of cases did not allow us to clarify this point. It is noticeable, however, that the smallest proportion of maternal deaths occurred on Sundays.
Just as in less develo ped po pulatio ns, there is an abso lute predo minance o f direct o bstetric causes and amo ng them, in o rder o f prevalence, hypertensio n and po st-partum hemo rrhage. It is w o rth re me mb e ring tha t the p re va le nc e o f
Table 5 - Distribution of maternal deaths according to avoidance and responsibility (Campinas,1985-1991).
AVO IDANCE/ RESPO NSIBILITY n %
Avo idable 4 6 7 4 .2
Ho spital care 2 2 3 5 .5
Medical care 1 5 2 4 .2
So cial 2 3 .2
Ig no red 7 1 1 .3
N o t avo idable 1 2 1 9 .4
Ig no red 4 6 .5
hypertensio n o ver hemo rrhage is a characteristic o f po pulatio ns with an intermediary develo pment situatio n, which demo nstrates the greater need fo r actio ns at the prenatal level. Co nsidering that the majority of women had prenatal care, the emphasis sho uld be placed o n its quality, o n the o ppo rtunities fo r referring them to a seco ndary o r tertiary level and o n the facilities fo r their receptio n there.
In additio n, the fact that delayed blo o d transfusio n o ccurred in 6 % o f the cases o f death, and in 1 4 % o f the cases that had blo o d transfusio n, demo nstrates an institutio nal difficulty in o btaining hemo therapy services, which is no t in acco rdance with the city’s health situatio n.
Another important point is the fact that 3% of the cases had an abortion as the basic cause of death, confirming some recent publications that suggested that maternal mortality due to abortion in Brazil is less than was suspected for this period. The percentage of maternal deaths from abortion was even lower than the 7.6% identified for all maternal mortality committees of Paraná state in 1990.7 It could also be a rg ue d tha t w ith a p rivile g e d he a lth a nd socioeconomic situation, Campinas, as well as Paraná state, would not be representative of the whole country. However, similar findings are reported from other studies throughout the country.8,12,19
Co ncerning the incidence o f abo rtio n, the spread and g eneralized use o f miso pro sto l, a synthetic pro staglandin which stimulates uterine activity and which is empirically used by wo men a s a n a b o rtifa c ie nt, sub stituting o the r mo re dangero us metho ds, sho uld be taken into acco unt, altho ugh there is very little data available o n it. But it do es seem to have highly reduced the pro file o f mo rbidity and mo rtality fro m induced abo rtio n in Brazil. It sho uld also be no ted that the use o f this pro staglandin was particularly frequent in the final five years included in the present study.
The mo st impo rtant result fro m this study p ro b a b ly re la te s to the a vo id a nc e o f a nd responsibility for maternal deaths. W hile it is possible to conclude that three-quarters of these deaths could have been avoided with some kind of measures, it is also po ssible to have a clearer idea o f the significance of these deaths and of measures directed towards reducing them. Although the total number
of maternal deaths in Campinas city, as well as its MMR, are not very high in a Brazilian context, and mo reo ver, co nsidering the relatively privileg ed situation of the municipality in terms of health and so cio eco no mic facto rs, it is inadmissible that this prevalence of avoidable direct obstetric maternal deaths should continue. It is important to consider, however, that the smaller the number of maternal deaths, the more difficult it will be to reduce them further.
In a retro spective study like this, based o n review o f clinical reco rds, o ften inco mplete, it is an extremely difficult task to attribute respo nsibilities fo r the deaths, especially when the respo nsibility is shared, as is the case fo r the majo rity o f them. W ith these pro viso s, the predo minance o f ho spital and physician respo nsibility o ver so cial causes suggests that avo idance sho uld be even easier and almo st exclusively dependent o n the health secto r.
CONCLUSIONS
W ithin the study perio d, 3 9 maternal deaths were identified thro ug h death certificates and ano ther 2 3 after the co mplementary investigatio n pro cess, giving a to tal o f 6 2 maternal deaths fo r the municipality during a seven year perio d. This co rrespo nded to an average percentage o f under-registratio n o f maternal deaths o f 3 7 .1 % and to an estimate of the confirmed MMR of 4 5 .5 maternal deaths per 1 0 0 ,0 0 0 LB, as o ppo sed to the o fficial MMR o f 2 8 .6 per 1 0 0 ,0 0 0 LB.
The majority of the maternal deaths identified had as their basic cause a direct obstetric factor and, among them, hypertension was the most frequent and
Ta ble 6 - distribution of ma terna l dea ths a ccording to blood tra nsfusion a nd opportunities for it,
Ca mpina s, 1 9 8 5 -1 9 9 1
BLO O D TRAN SFUSIO N n %
Yes 2 8 4 5
O ppo rtune 2 4 3 9
N o t o ppo rtune 4 6
N o 2 1 3 4
Ig no red 1 3 2 1
responsible for around one third of all deaths. Three-q ua rters o f these dea ths were c o nsidered a s avoidable, especially via measures at the level of hospital and medical care, reinforcing the importance of strategies to be taken at the public health level for improving the quality of care and, consequently, reducing these avoidable maternal deaths.
REFERENCES
1. Ro senfield A, Maine D. Maternal mo rtality: a neglected tragedy. Where is the M in MCH? Lancet 1985; 13:83-5.
2. Mahler H. The safe mo therho o d initiative: a call to actio n. Lancet 1987; 21:668-70.
3. Starrs A. La prevenció n de la tragédia de las muertes maternas: info rme so bre la Co nferencia Internacio nal so bre la Maternidad sin Riesgo . Nairo bi, Kenya: Febrero 1987; 56.
4. Cecatti JG. Análise da mo rtalidade materna no município de Campinas no perío do de 1985 a 1991. Tese de Do uto rado . Faculdade de Ciências Médicas da Universidade Estadual de Campinas. Campinas: 1992.
5. Brasil. Ministério da Saúde. Manual dos Comitês de Mortalidade Materna. Secretaria de Assistência à Saúde, Departamento de Assistência e Promoção à Saúde, Coordenação Materno-Infatil. Brasília: COMIN 1994.
6. Braga LFCO, So ares VMN. Implantação do s co mitês de mo rte materna no Paraná. Femina 1990; 18:432-6.
7. Braga LFCO, Nazareno ER, Fanini ML, Carvalho MTW, So ares VMN, Hirata VM. Relató rio do co mitê de mo rte materna do Paraná, 1990. Femina 1992; 20:186-95.
8. Becker RA, Lechtig A. Brasil: aspecto s da mo rtalidade infantil, pré-es-co lar e materna. Brasília: Ministério da Saúde 1987; 45.
9. Laurenti R. Marco s referenciais para estudo s e investigaçõ es em mo rtalidade materna. Rev Saúde Públ 1988; 22:507-10.
10. Faúndes A, Herrmann V, Cecatti JG. Análise da mo rtalidade materna em parto s cesáreo s, no município de Campinas, 1979-1983. Femina 1985; 13:516-24.
11. Cecatti JG, Faúndes A. Intervenções para aperfeiçoar o conhecimento sobre o número e as causas de mo rtes maternas. Femina 1989; 17:389-92.
12. Laurenti R, Buchalla CM, Lo lio CA, Santo AH, Jo rge MHPM. Mo rtalidade de mulheres em idade fértil no município de São Paulo (Brasil),1986. II - Mo rtes po r causas maternas. Rev Saúde Públ 1990; 24:468-72.
13. So uza ML, Laurenti R. Mo rtalidade materna: co nceito s e aspecto s estatístico s. Centro da OMS para a classificação das do enças em po rtuguês (MS/USP/OPAS - OMS). São Paulo : Série Divulgação 1987; 3:34.
14. Magnin P, Nico llet B. La mo rtalité maternelle en France. Bull Acad Nat Med 1981; 156:653-9.
15. Ro chat RW, Ko o nin LM, Atrash HK, Jewett JF. Maternal mo rtality in the United States: repo rt fro m the maternal mo rtality co llabo rative. Obstet Gyneco l 1988; 72:91-7.
16. Smith JC, Hughes JM, Peko w PS, Ro chat RW. An assessment o f the inci-dence o f maternal mo rtality in the United States. Am J Public Health 1984; 74:780-3.
17. Faúndes A, Cecatti JG. Mo rte materna: uma tragédia evitável. Campinas: Edito ra da UNICAMP 1991; 217.
18. Ro ysto n E, Armstro ng S. Preventing maternal deaths. Geneve: Wo rld Health Organizatio n 1989; 233.
19. Ferreira CEC, Ceneviva PVS. Mo rtes maternas. Rev Fund SEADE/São Paulo em perspect 1986; 2:17-24.
ACKNOWLEDGEMENTS
O ur thanks to the SEADE Fo undatio n o f São Paulo state fo r making info rmatio n available fro m death certificates and to the ho spitals o f Campinas fo r facilitating access to clinical reco rds fo r the investig atio n o f maternal deaths.
RESUMO
O bjetivos: Estudar o número e as características das mo rtes maternas, suas causas e evitabilidade, entre mulheres residentes
no município de Campinas no perío do de 1 9 8 5 a 1 9 9 1 , identificadas entre to das as declaraçõ es de ó bito de mulheres co m idade entre 1 0 e 4 9 ano s.
Tipo de estudo: Estudo descritivo de base po pulacio nal, retro spectivo .
M étodo: Selecio naram-se, dentre to das as D.O . eleg íveis ao estudo , as classificadas quanto à causa básica do ó bito co mo mo rtes maternas declaradas e presumíveis, seg undo o s critério s de Laurenti, que fo ram co mplementarmente estudadas através de seus pro ntuário s clínico s.
Resulta dos: Identificaram-se 3 9 mo rtes maternas declaradas e um to tal de 6 2 co nfirmadas ao fim do estudo ,
co rrespo ndendo a uma subenumeração de 3 7 ,1 % e a uma RMM de 4 5 ,5 po r 1 0 0 .0 0 0 N V. Cerca de três quarto s do s ó bito s materno s aco nteceram po r uma causa o bstétrica direta e fo ram co nsiderado s evitáveis.
Conclusão:A mortalidade materna ainda é elevada no município de Campinas, embora bem menor que a média estimada para o
Brasil. O predomínio de causas obstétricas diretas e de óbitos evitáveis reforça a necessidade de medidas de saúde pública para evitá-los. Fro m O bstetrics unit, Department o f G yneco lo g y and O bstetrics, Scho o l o f Medical Sciences,
Universidade Estadual de Campinas - SP - Braz il.
Authors
José Guilherm e Ceca tti - O bstetrician and
epidemio lo g ist senio r lecturer o f o bstetrics.
Aníba l Fa úndes - Full pro fesso r o f o bstetrics.
Ferna nda Ga ra nha ni de Ca stro Surita - Master in
O bstetrics.
Sources of Funding: N o t declared
Conflict of interest: N o t declared
La st received: 2 9 April 1 9 9 8
Accepted: 2 6 N o vember 1 9 9 8
Address for correspondence:
Jo sé G uilherme Cecatti
Seto r de O bstetrícia - Departamento de To co g ineco lo g ia Faculdade de Ciências Médicas
da Universidade Estadual de Campinas
