Severe acute maternal morbidity: use of the Brazilian Hospital Information System

[Spatial analysis of maternal morbidity and mortality in users of the Brazilian Unified National Health System in the city of Rio de Janeiro, Brazil, 2014-2016]

The objective of this study is to analyze the maternal morbidity and mortality of women treated in hospitals of the Brazilian Unified National Health System (SUS) in the city of Rio de Janeiro in the period 2014-2016. An ecological study was conducted using data from the Brazilian Information System on Live Birth (SINASC), the Brazilian Mortality Information System (SIM), and the Brazilian Hospital Information System (SIH/SUS). For the analysis of the maternal mortality ratio (MMR), data from the SIM were used. For the analysis of maternal morbidity, World Health Organization criteria were used to estimate the ratios of maternal near miss and potentially life-threatening conditions. SINASC was used to retrieve data on the number of live births, for demographic characterization, social aspects, and access to prenatal care. To evaluate the spatial association between the indicators MMR, ratios of maternal near miss, and potentially life-threatening conditions and the demographic, social, obstetric, and access indicators, obtained from SINASC, the bivariate Moran Index was estimated with a significance level of 0.05, using the GeoDa program. In the period analyzed, the MMR in the Rio de Janeiro was 94.16/100,000 live births, the ratio of maternal near miss was 28.21/1,000 live births, and the potentially life-threatening conditions was 34.31/1,000 live births. Cases of potentially life-threatening conditions were used for the first time in this study and presented diagnoses and procedures during hospitalization more consistent with the maternal mortality profile in the city of Rio de Janeiro. There was a significant association between MMR and percentage of live births in SUS, potentially life-threatening conditions and percentage of live births in SUS, and potentially life-threatening conditions and being single.

[Maternal morbidity and mortality in Brazil and the urgency of a national surveillance system for maternal near miss]

The World Health Organization (WHO) recommends the analysis of severe maternal morbidity/maternal near miss cases as complementary to the analysis of maternal deaths since the incidence is higher and the predictive factors of the two outcomes are similar. Considering that the reasons for maternal mortality in Brazil have remained constant despite the commitment made during the General Assembly of the United Nations in 2015, this article aims to propose a nationwide maternal near miss surveillance system. We propose the inclusion of maternal near miss events in the National List of Compulsory Notification of Diseases, Injuries, and Public Health Events, via the compatibility of the diagnostic criteria of maternal near miss, informed by the WHO, with the codes of the International Classification of Diseases for the identification of cases. Considering that health surveillance is based on several sources of information, notification could be made by health service professionals as soon as a confirmed or suspected case is identified. With the study of the factors associated with the outcomes, we expect a qualified evaluation of the services focused on obstetric care and consequent implementation of more efficient policies to prevent not only maternal death but also events that can both cause irreversible sequelae to women's health and increase the risk of fetal and neonatal death.

[Clinical complications during pregnancy: a systematic review of studies with pregnant Brazilian women]

The scope of this paper was to describe the main clinical complications among pregnant Brazilian women reported in the literature, identifying the most relevant exposure factors and their outcomes in maternal and child health. This is a systematic review of articles published between 2010 and 2018. Three reviews and 36 empirical articles were included; mental disorders (n=9), infectious diseases (n=9) and severe maternal morbidity (n=8) were the main clinical complications during pregnancy. In addition, four articles focused on determining the main conditions or causes of hospitalization, with a higher frequency of Urinary Tract Infection, anemia and hypertensive diseases. Maternal age at reproductive extremes, lower schooling, socioeconomic vulnerability, racial characteristics and the use of public health services were the most relevant exposure factors. Unfavorable health outcomes associated with clinical complications in pregnancy were verified in the eight articles with this profile. The frequency of pregnant women with potential life-threatening clinical complications is high in the country, highlighting the importance of primary care coverage and the implementation of interventions to reduce and prevent adverse maternal and child outcomes.

Temporal trends of maternal near miss in Brazil between 2000 and 2012

Abstract Objectives: to identify the temporal trends and regional variations in maternal near miss in Brazil. Methods: ecological study of temporal trends. The units of analysis are in the States, the regions and Brazil, between 2000 and 2012, the dependent variable being the maternal near miss rate (MNMR), calculated from the records of the Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS) (National Health Hospital Information System).Regression analysis using Joinpoint regression software, version 4.1.0. was applied to analyze morbidity trends. Results: the main result of this study was a finding on an increase rate trend in maternal near miss in Brazil, between 2000 and 2012. This trend behaves differently depending on the development level of the region studied, presenting a positively higher increase in less developed regions and states. Conclusions: there is an increasing trend in maternal near miss rates in Brazil. The SIH-SUS may be an important instrument in identifying and monitoring maternal morbidity. Furthermore, investments in more effective public policies are needed to reduce inequalities and improve human development, both of which have influenced the chain of events related to maternal health.

Concepts, prevalence and characteristics of severe maternal morbidity and near miss in Brazil: a systematic review

Abstract Objectives: to analyze frequency, characteristics and causes of severe maternal morbidity (maternal near miss) in Brazil. Methods: a systematic review on quantitative studies about characteristics, causes, and associated factors on severe maternal morbidity (maternal near miss). The search was done through MEDLINE (maternal near miss or severe maternal morbidity and Brazil) and LILACS (maternal near miss, maternal morbidity). Data were extracted from methodological characteristics of the article, criteria for maternal morbidity and main results. Near miss ratios and indicators were described and estimated. Results: we identified 48 studies: 37 were on hospital based; six were based on health surveys and five were based on information systems. Different definitions were adopted. Maternal near miss ratio ranged from 2.4/1000 LB to 188.4/1000 LB, depending on the criteria and epidemiological scenario. The mortality rate for maternal near miss varied between 3.3% and 32.2%. Hypertensive diseases and hemorrhage were the most common morbidities, but indirect causes have been increasing. Flaws in the healthcare were associated to near miss and also sociodemographic factors (non-white skin color, adolescence/ age ≥ 35 years old, low schooling level). Conclusions: the frequency of maternal near miss in Brazil is high, with a profile of similar causes to maternal mortality. Inequities and delays in the healthcare were identified as association.

[Hospitalizations due to complications of pregnancy and maternal and perinatal outcomes in a cohort of pregnant women in the Brazilian Unified National Health System in São Paulo, Brazil]

Maternal morbidity, fetal mortality, and neonatal mortality are important indicators of maternal and child health. The study aimed to describe maternal and perinatal outcomes (low birth weight, prematurity, fetal and neonatal deaths, postpartum hospitalizations, and readmission of newborns) in a cohort of pregnant women whose deliveries were covered by the Brazilian Unified National Health System (SUS) in the city of São Paulo, Brazil, in the second semester of 2012. We obtained a retrospective cohort of 55,404 pregnant women with deterministic and probabilistic linkage of data from the Hospital Information System of the SUS (SIH/SUS), Information System on Live Births (SINASC), Mortality Information System (SIM), and National Registry of Health Establishments (CNES) databases. Hospitalizations due to obstetric complications occurred in 4.3% of the women. The most frequent diagnoses were infection, hypertensive disease of pregnancy, and diabetes. Hospitalizations prior to childbirth were more common in pregnant women 35 years or older and those with a history of multiple pregnancies and low schooling. Postpartum hospitalizations were three times greater and maternal mortality was nine times greater in pregnant women with a history of previous hospitalization due to obstetric complications. Adverse perinatal outcomes (fetal and neonatal mortality and low birth weight) were twice as frequent in infants of women with previous hospitalization when compared to those without. A similar pattern was seen in hospitalization of newborns soon after birth and in hospital readmission. Adverse maternal and perinatal outcomes were more frequent in pregnant women with a history of previous hospitalization.

[Maternal near misses and health inequalities: an analysis of contextual determinants in the State of Rio Grande do Norte, Brazil]

The scope of this study was to identify socioeconomic contextual and health care factors in primary care associated with maternal near misses and their marker conditions. This is an ecological study that used aggregated data of 63 clusters formed by the municipalities of State of Rio Grande do Norte, Brazil, using the Skater method of area regionalization, as the unit of analysis. The ratio of maternal near misses and their marker conditions were obtained from the Hospital Information System of the Brazilian Unified Health System. In multiple linear regression analysis, there was a significant association between maternal near misses and variables of poverty and poor primary health care. Hypertensive disorders were also associated with poverty and poor primary care and the occurrence of hemorrhaging was associated with infant mortality. It was observed that the occurrence of maternal near misses is linked to unfavorable socioeconomic conditions and poor quality health care that are a reflection of public policies that accentuate health inequalities.

Near miss e mulheres negras

Resumo Introdução: A mortalidade materna apresenta grande diferença entre os países desenvolvidos e em desenvolvimento e espelha a qualidade da assistência prestada à saúde da mulher. Para evidenciar melhor essa assistência, novos métodos de estudo vêm sendo utilizados, entre eles a investigação das morbidades maternas graves - near misses. Objetivo: Analisar os fatores de risco para ocorrência de near miss nas diferentes raças/cores das mulheres residentes em três municípios da Região Metropolitana de Curitiba. Método: Estudo descritivo. Resultados: Na análise multivariada, identificou-se ser as variáveis idade (p=0,0321 com OR 3,08 e IC 95% 1,10-8,65), doenças associadas (p=0,0018 com OR 4,06 e IC 95% 1,61-10,24) e causa de internação (p=<0,0001 com OR 8,75 e IC 95% 3,36-22,75) os fatores de risco para near miss; o OR foi estimado com base no modelo multivariado. Já a variável cor não foi identificada como sendo fator de risco para near miss (p=0,8964) na presença das demais variáveis. Conclusões: Evidenciou-se, no estudo, a necessidade de aprofundar a análise em pesquisas sobre ocorrência de near miss e cor da variável idade e outras causas de internação para mulheres brancas, e a paridade/número de gestações e presença de doenças crônicas ou associadas para as mulheres negras, assim como a instituição de outros parâmetros de análise como as transferências e reinternações.

Temporal evolution and spatial distribution of maternal death

OBJECTIVE

To analyze the temporal evolution of maternal mortality and its spatial distribution.

METHODS

Ecological study with a sample made up of 845 maternal deaths in women between 10 and 49 years, registered from 1999 to 2008 in the state of Rio Grande do Sul, Southern Brazil. Data were obtained from Information System on Mortality of Ministry of Health. The maternal mortality ratio and the specific maternal mortality ratio were calculated from records, and analyzed by the Poisson regression model. In the spatial distribution, three maps of the state were built with the rates in the geographical macro-regions, in 1999, 2003, and 2008.

RESULTS

There was an increase of 2.0% in the period of ten years (95%CI 1.00;1.04; p = 0.01), with no significant change in the magnitude of the maternal mortality ratio. The Serra macro-region presented the highest maternal mortality ratio (1.15, 95%CI 1.08;1.21; p < 0.001). Most deaths in Rio Grande do Sul were of white women over 40 years, with a lower level of education. The time of delivery/abortion and postpartum are times of increased maternal risk, with a greater negative impact of direct causes such as hypertension and bleeding.

CONCLUSIONS

The lack of improvement in maternal mortality ratio indicates that public policies had no impact on women's reproductive and maternal health. It is needed to qualify the attention to women's health, especially in the prenatal period, seeking to identify and prevent risk factors, as a strategy of reducing maternal death.