A major difficulty has been the lack of a standard definition and methodology for assess- ment of non-life threatening maternalmorbidity. Previous studies describing maternal mor- bidity each include one or several of a wide spectrum of conditions ranging from short-term major complications such as obstetric haemorrhage and eclampsia, to long-term conditions such as obstetric fistula or anaemia in varying combinations [18–21]. In addition, much of the information and evidence reported to date is from hospital-based small studies with reporting and selection biases or is found in the grey literature as reports and surveys. Thus, there is cur- rently a lack of information and understanding regarding prevalence and burden of maternalmorbidity that is not immediately life threatening and even less data on psychological morbid- ity associated with pregnancy, particularly in rural areas of developing countries in Asia and Africa.
The study has strengths. First, its population is similar to that of numerous other studies, and the sample represents epidemio- logically the obstetric population in economically disadvantaged regions, thereby allowing its findings to be extrapolated to other locations in Brazil and other countries. Second, the 1-year study period should take into account all possible seasonal interferences. Third, its approach was directed toward the criteria of near miss and severe maternalmorbidity in an obstetric and neonatal referral cen- ter.Thespecificassociationofeachoneofthesecriteriawaseval- uated directly, in addition to how the interference between them can contribute to maternal death, identifying those that are prin- cipallyresponsiblefortheunfavorableoutcomeinthispopulation. Accordingly,inapopulationclassifiedasseverematernalmorbidity ornearmiss,asdefinedbyWHO,themaindeterminingcriteriafor maternal death were eclampsia, low oxygen saturation, need for admission in ICU, need for intubation, mechanical ventilation, and cardiopulmonary resuscitation. The use of magnesium sulfate was foundtobeaprotectivefactor.
This study has some limitations that are worth noting. First, the non-random nature of the facility sampling process may have introduced some level of selection bias, potentially impairing the country representativeness of this study. On the other hand, the convenience sampling approach was realistic and made this study feasible. Precautions have been taken to maximize country representativeness. An analysis based on the intra-cluster correla- tion coefficients provided some evidence supporting the success of these precaution measures . Second, this study is largely based on information obtained from medical records. In order to reduce the chances of recording bias, information from medical records was complemented with information obtained directly from the assisting staff (if relevant information was missing and in case of doubt). In addition, several procedures to optimize quality of data have been put in place. Third, the study population is essentially provided by referral hospitals which tend to concentrate the more severe cases: the MMR observed in this study is about three times the overall MMR estimated for the country. Another aspect that deserves noting is the relationship between the various covariates within the MSI model. The maternal severity score (i.e. the total number of severity markers present in each case) is positively correlated with maternal mortality and as the number of life- threatening conditions increase, the death probability increases. If a life-threatening condition is identified at hospital arrival or within the first 24 hours of hospital stay, there is an increase in the risk of death, possibly denoting the fact that the woman has arrived in the hospital already in a very severe condition. Cancer and a cardiovascular or respiratory failure substantially increase the death risk. Two covariates (i.e. severe pre-eclampsia and hysterectomy) have negative coefficients denoting a ‘‘protective’’ association within the model. At the first glance this may seem counterintuitive, but these negative coefficients have to be considered in the context of severe maternalmorbidity. Our Table 3. Cont.
MaternalMorbidity, (N=272), women who have recently given birth without complication of serious obstetric complications, totaling 549 subjects. Participants who did not live in Sergipe State were excluded from the groups, those who were born with serious disabilities, who died, and/or those with medical restriction due to the severity of the case, because of these situations, they com- promised the emotional state, and act as a confounding variable. Mônica Silva Silveira E-mail: firstname.lastname@example.org
Objective: to analyze the scientific evidence about the factors influencing maternal near miss cases and possible guidelines for reducing maternalmorbidity and mortality. Methods: integrative review with 2895 articles found and 17 selected articles. Results: the factors influencing the near miss cases were: delays in obstetric care; unprepared health team; precarious conditions of services; limited availability of blood derivatives; and prenatal disability, the limited use of evidence-based practices and audits. As main directions to minimize these events, we have evidenced: to strengthen the network of reference and counter-reference; carry out professional training; improve prenatal coverage; and invest in infrastructure, process management and clinical audits. Conclusion: the factors that influence the maternal near miss cases range from delayed care to failure to perform prenatal care, whose management improvement is the main direction.
The authors acknowledge the involvement of the members of its Steering Committee and all the other investigators and coordinators from all the centres involved in the National Network for the Surveillance of Severe MaternalMorbidity. The authors acknowledge the contribution of the Brazilian Network for the Surveillance of Severe MaternalMorbidity Group: Joa˜o P Souza, Rodolfo C Pacagnella, Rodrigo S. Camargo, Vilma Zotareli, Lu´cio T. Gurgel, Lale Say, Robert C Pattinson, Marilza V Rudge, Iracema M Calderon, Maria V Bahamondes, Danielly S Santana, Simone P Gonc¸alves, Eliana M Amaral, Olı´mpio B Moraes Filho, Simone A Carvalho, Francisco E Feitosa, George N Chaves, Ione R Brum, Gloria C Saint’Ynes, Carlos A Menezes, Patricia N Santos, Everardo M Guanabara, Elson J Almeida Jr, Joaquim L Moreira, Maria R Sousa, Frederico A Peret, Liv B Paula, Luiza E Schmaltz, Cleire Pessoni, Leila Katz, Adriana Bione, Antonio C Barbosa Lima, Edilberto A Rocha Filho, Melania M Amorim, Debora Leite, Ivelyne Radaci, Marilia G Martins, Frederico Barroso, Fernando C Oliveira Jr, Denis J Nascimento, Cla´udio S Paiva, Moises D Lima, Djacyr M Freire, Roger D Rohloff, Simone M Rodrigues, Sergio M Costa, Lucia C Pfitscher, Adriana G Luz, Daniela Guimaraes, Gustavo Lobato, Marcos Nakamura-Pereira, Eduardo Cor- dioli, Alessandra Peterossi, Cynthia D Perez, Jose C Perac¸oli, Roberto A Costa, Nelson L Maia Filho, Jacinta P Matias, Silvana M Quintana, Elaine C Moises, Fa´tima A Lotufo, Luiz E Carvalho, Carla B Andreucci, Ma´rcia M Aquino, Maria H Ohnuma, Rosiane Mattar and Felipe F Campanharo.
One third of the women presented complications related to abortion, among which highlighted the need for surgical interventions and blood transfusion, septic shock and/or hypovolemic, sepsis and death. Even though these complications do not cause death, it can result in irrevers- ible sequelae to medium and long term as the infertility and chronic pelvic pain, causing major impact on maternal health. Similar results were found in a systematic review on the incidence of severe maternalmorbidity associated with abortion, which showed a higher incidence of serious complications when compared to deaths due to abortion 17 .
characteristics of severe maternalmorbidity have only recently begun to receive more specific attention, albeit the potential of this subject as basis for the development of public policies remains to be evaluated. Therefore, demographic health surveys may be a valuable source of information on maternalmorbidity, particularly in locations where integrated epidemiological surveillance with wide geographical coverage is yet to be established 7 .
Objective : to know and analyze the experiences of women who developed an episode of Severe MaternalMorbidity. Method: this is a qualitative study, in which we interviewed 16 women admitted to a tertiary level hospital, as a result of this morbid state. We used content analysis in data processing. Results: two categories were identifi ed: “Understanding maternalmorbidity as a negative presence” and “Moving ahead: on constant alert”. The interviewees mentioned negative aspects, such as treatment diffi culties and hospitalization, feelings of fear, concern for the fetus, frustration with the idealized pregnancy, trauma; and positive aspects, such as learning and the expression of the divine will in the experience of illness. Conclusion: effective care during the prenatal period, delivery and postpartum period should provide adequate support for the prevention and assistance in Severe MaternalMorbidity. Descriptors: Maternal Welfare; Maternal Health; Pregnancy Complications; High Risk Pregnancy; Morbidity.
the present day few countries display mortality in excess of 1,000 maternal deaths per 100,000 live births. This trend, known as “obstetric transi- tion”, is also associated with lower fertility rates, aging of the obstetric population, changes in the pattern of causes of morbidity and mortal- ity (with chronic degenerative diseases gaining importance) and increasing institutionalization of care at childbirth. Use of health technologies favors reduction in maternalmorbidity and mor- tality, but hyper-medicalization – or the excessive and unnecessary use of health technology in care during pregnancy and childbirth – also represent risks for women, fetuses and newborns. In the later stages of the obstetric transition, when ma- ternal mortality falls below 50 maternal deaths per 100,000 live births, the risks associated with the hyper-medicalization of maternity become more evident 4 .
Abstract Twin pregnancy accounts for 2 to 4% of total births, with a prevalence ranging from 0.9 to 2.4% in Brazil. It is associated with worse maternal and perinatal outcomes. Many conditions, such as severe maternalmorbidity (SMM) (potentially life-threatening conditions and maternal near-miss) and neonatal near-miss (NNM) still have not been properly investigated in the literature. The difﬁculty in determining the conditions associated with twin pregnancy probably lies in its relatively low occurrence and the need for larger population studies. The use of the whole population and of databases from large multicenter studies, therefore, may provide unprecedented results. Since it is a rare condition, it is more easily evaluated using vital statistics from birth e-registries. Therefore, we have performed a literature review to identify the characteristics of twin pregnancy in Brazil and worldwide. Twin pregnancy has consistently been associated with SMM, maternal near-miss (MNM) and perinatal morbidity, with still worse results for the second twin, possibly due to some characteristics of the delivery, including safety and availability of appropriate obstetric care to women at a high risk of perinatal complications.
Among the previous pathologies associated with pregnancy, five had Systemic Arterial Hypertension and two Diabetes Mellitus. Pregnancy can stimulate SAH in previously normotensive women or worsen a picture of previous chronic hypertension. It is known that hypertensive syndromes in pregnancy are important causes of maternalmorbidity and mortality in Brazil. Increased blood glucose can also increase the incidence of pre- eclampsia in pregnancy, the chance of developing diabetes, and decreased tolerance to carbohydrates after pregnancy. 2
METHODS: Data from the Hospital Information System, obtained from the Municipal Secretariat of Health of the city of Juiz de Fora, Southeastern Brazil, for the years 2006 and 2007, were used. The studied women included those admitted to the hospital for obstetric procedures (n = 8,620), and whose primary diagnosis was included within chapter XV: pregnancy, childbirth and puerperium of the International Classiﬁ cation of Diseases, 10th revision. Codes for routine procedures, special procedures, and professional acts that fulﬁ lled the World Health Organization’s criteria for severe acute maternalmorbidity were identiﬁ ed, as well as other procedures infrequently employed during pregnancy and the postnatal period. Logistic regression analysis was employed to identify associations between the outcome and selected variables. RESULTS: Prevalence of maternalmorbidity was 37.8/1000 women, and that of mortality was 12/100,000 women. Hospitalization for more than 4 days was 13 times more frequent among women with some form of morbidity. After adjustment, predictors of severe acute maternalmorbidity were: duration of hospitalization, number of hospitalizations, and stillbirths, and the most frequent procedures and conditions were blood product transfusions (15.7/1,000), “extended stay” (9.5/1.000) and severe pre-eclampsia/eclampsia (8.2/1,000). CONCLUSIONS: Prevalence of severe acute maternalmorbidity was high, and was related especially to hospitalization and to newborn variables. The criterion for identifying cases and the use of the National Hospital Information System proved to be useful for monitoring maternalmorbidity and mortality and increasing our knowledge of its related aspects, contributing to the improvement of the quality of pregnancy and delivery care.
Although not a formal part of the present study, the finding that 14 women who suffered an episode of severe maternalmorbidity in the institution died at some point between this episode and the attempt to contact them by telephone is very important. Other authors have also reported a higher postpartum mortality rate in women with a history of a near-miss. A prospective cohort study showed that both women who had severe obstetrical complications and their babies were significantly more likely to die within one year of hospital discharge compared to the respective controls. 19 In another study, a mortality rate of around 10% was found in women during the follow-up period (18 months to 12 years) after an episode of pregnancy-related hospitalization in an ICU. 21
Introduction – The study of maternalmorbidity contributes to a better understanding of the maternal health scene in Brazil and to the fuller knowledge of obstetric problems that may lead (or not) to the hospitalization of pregnant women. Maternalmorbidity data are vital for the administrators of public health policies, who need to know how many women are expected to need basic obstetric care so as to make pregnancy and delivery safer. Objectives – To study maternalmorbidity and the conceptuses of puerperae in a public maternity hospital in João Pessoa, Paraíba, and identify women with a diagnosis considered potentially threatening and suggestive of being possible near misses. Method - This is a transverse study that is part of a larger project on maternal morbimortality. A sample of 414 puerperae was selected by a process of systematic random sampling, the data on whom were collected, prospectively, from September to November 2011, on the basis of clinical case notes and complementary interviews, at a public maternity hospital of reference in great demand in the municipality. Results - A total of 383 pregnancies which were carried through to delivery and 391 conceptuses were studied. There predominated, among the puerperas: the 20 - 34 year age-group, of brown skin color, low level of schooling, low income and no formal professional occupation. Half of them underwent caesarian section and 17% of the new-born presented health problems. The following incidents were identified during labour: lacerations of the perineum, haematomas, traumatisms, haemorrhages and hypertensions. During the puerperium, hypertensive disorders, post-partum hemorrhage and other puerperal infections were noteworthy. The most frequent mention in the case notes of maternal causes was of hypertensive disturbances of pregnancy. Among the 64 diagnoses suggestive of near- miss
Initially, a meeting was held during the Brazilian national congress of Gynecology and Obstetrics in November, 2007, and attended by representatives of 35 healthcare facilities in Brazil. At this meeting, the main points fea- tured in the initial concept of the project were presented and an invitation was made to institutions interested in participating in a Brazilian network on the topic. Those who were interested in participating filled out a registra- tion form with the addresses and characteristics of their respective healthcare institutions. In December 2007, an electronic form was sent to them to be completed with specific information. In accordance with the data received, 27 of these candidate healthcare institutions were selected to participate in the network, taking regional characteris- tics, geographic distribution, level of complexity and the number of deliveries performed into consideration. In August 2008, a meeting with representatives from all the centers was held at the coordinating center in Campi- nas. At this meeting, the proposal was presented and dis- cussed in detail, and suggestions were incorporated into the final version of the protocol. Participating center rep- resentatives were identified, the operational issues involved in implementing the study and the theoretical concepts were discussed, and the final version of the research project was defined. Concurrently, a signed com- mitment was undertaken by each representative to partic- ipate in the Brazilian Network for the Surveillance of Severe MaternalMorbidity: the Brazilian Network of Stud- ies in Reproductive and Perinatal Health was created. A Steering Committee was also designated for the study.
Cervical ectopic pregnancy (EP) is an infrequent, life-threatening form of ectopic gestation pregnancy that implants within the endocervical canal. With the increase in use of assisted reproductive technology (ART) worldwide and more liberal use of transvaginal sonography (TVS) during early pregnancy, more cases of cervical ectopic pregnancy are being diagnosed. Early diagnosis of this condition by using ultrasound imaging allows for prevention of maternalmorbidity due to hemorrhage and leads to conservative management of this condition.We present the case of a 38-year old woman (gravida 1, para 0) who was found to have acervical ectopic pregnancy at six weeks of gestation.
Peripartum cardiomyopathy (PPCM) was defined, according to Sliwa et al., as ‘an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. It is a diagnosis of exclusion. The LV may not be dilated but the ejection fraction (EF) is nearly always reduced below 45%’.  Hypertrophic cardiomyopathy was defined as echographically proven hypertro- phied, non-dilated left ventricle in the absence of another systemic or cardiac disease that is capable of producing the same magnitude of wall thickening. Dilated cardiomyopathy was defined as an EF of ,40% in the presence of increased left ventricular dimension, without other cause. Where possible, cases of arrhythmia were further specified as supraventricular tachycardia (SVT) or ventricular tachycardia (VT). SVT was defined as any tachycardia that was not ventricular in origin (ectopic atrial tachycardia, atrial fibrillation, atrial flutter and junctional tachycardia). VT was defined as tachycardia with ventricular origin, based on a 12-lead electrocardiography (ECG). Valvular disease was defined as cardiac valve stenosis or regurgitation when the diagnosis was made upon a heart murmur and symptoms in combination with echocardiographic abnormalities. Valvular disease was further specified into CHD, rheumatic disease or endocarditis based on the origin of valvular dysfunction. Ischaemic heart disease was defined as maternal complaints of chest pain accompanied by either rise of cardiac markers or ECG changes. Acute coronary syndrome was proven by raised cardiac markers (troponin .0.3 ug/l or CK-MB.170 U/l) in combination with complaints or ECG abnormalities. ST-depressions are known to occur rather frequently during caesarean section. These mild ECG abnormalities in the absence of any abnormal clinical or laboratory findings were considered mild maternalmorbidity and hence not included in the LEMMoN study. Sudden Arrhythmic (or Adult) Death Syndrome (SADS) is defined as sudden death in an adult for which no cause could be found.
When analyzing the data relating to sociodemographic data, it was found that many of the information provided are not reported for the construction of rate indicators. This information could be used as the basis for construction of adequate care to lowering rates of maternalmorbidity and mortality. Since HDP can be early diagnosed and treated, deaths related to this pathology should not be acceptable.
Objective. To assess quality of care of women with severe maternalmorbidity and to identify associated factors. Method. his is a national multicenter cross-sectional study performing surveillance for severe maternalmorbidity, using the World Health Organization criteria. he expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classiied as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic diiculty in accessing health services ( � < 0.001), delays related to quality of medical care (� = 0.012), absence of blood derivatives ( � = 0.013), diiculties of communication between health services (� = 0.004), and any delay during the whole process (� = 0.039). Conclusions. his is an example of how evaluation of the performance of health services is possible, using a benchmarking tool speciic to Obstetrics. In this study the MSI was a useful tool for identifying diferences in maternal mortality ratios and factors associated with nonadequate performance of care.