Research Article: Healthcare and sociodemographic conditions related to severe maternal morbidity in a state representative population, Federal District, Brazil: A cross-sectional study

Date Published: August 3, 2017

Publisher: Public Library of Science

Author(s): Douglas dos Santos Moreira, Muriel Bauermann Gubert, Mohd Noor Norhayati.


The concept of severe maternal morbidity (SMM)—a potentially life-threatening condition during pregnancy, childbirth or after termination of pregnancy—can be used as a quality indicator of the health care provided to mothers and children. The aim of this study was to investigate the SMM rate and the main factors associated with this condition among women living in the Federal District, Brazil.

We conducted a cross-sectional population-based sample survey using a structured questionnaire about the sociodemographic characteristics of the participants’ families. The data investigated included receipt of financial aid from the Federal Government, age, race, maternal educational level, prenatal care, mode of delivery, and serious complications during pregnancy and postpartum (SMM). 1042 mothers of children up to 1 year old were interviewed, representing a weighted estimated population of 36,724 mothers. The sample was representative of the whole Federal District state.

Mothers were between 19 and 34 years old (69%), most of them were brown or black (59.7%), and they had more than 9 years of education (81.2%). Prenatal care was adequate for 91.9% of them, the most common mode of delivery was Cesarean section (61.3%), and most deliveries took place in public hospitals (57.3%). The prevalence of low birth weight (< 2,500 g) was 8.1%. We found 2072 events of SMM in 2060 mothers (SMM rate: 5.6%). There was an association between higher occurrence of SMM and older age (OR: 1.40; 1.26–1.56), lower maternal educational level (OR: 3.29; 2.78–3.90), and inadequate prenatal care (OR: 1.28; 1.09–1.51). Receipt of financial aid was also associated to increased risk for SMM (OR: 1.31; 1.16–1.48). Cesarean section and low birth weight reduced the risk of SMM (decrease of 49.0% and 46.0%, respectively). The SMM rate in the Federal District was positively associated with higher maternal age, lower maternal educational level, inadequate prenatal care, and government financial aid program. Conversely, SMM was inversely associated with Cesarean delivery and low birth weight. This study showed that specific demographic groups are at higher risk for SMM. Therefore, actions should be focused primarily on those groups for greater effectiveness at reducing maternal mortality and providing better quality of maternal health care.

Partial Text

The World Health Organization (WHO) defines maternal death as “the death of a woman during pregnancy or within a period of 42 days after the end of the pregnancy, regardless of the pregnancy duration or location, from any cause related to or aggravated by pregnancy or by measures related to it, but not from accidental or incidental causes”[1]. Approximately 1,000 women die from pregnancy-related causes every day, and 10 million women have complications related to pregnancy worldwide every year[2]. Furthermore, 99% of maternal deaths occur in low income countries[3]. In Brazil, where almost all deliveries occur in hospitals (98.08%), the maternal mortality rate is estimated at 68.2 deaths per 100,000 live births[4].

We conducted a cross-sectional population-based study using data from the survey “Neonatal Call: diagnosis of health conditions and health care of maternal and child population in the Federal District (FD)”. Data were collected in August 2011, during the “D-Day” of the polio vaccination campaign in the Federal District, with mothers of children under 1 year of age, covering a large portion of the target population (99.4%)[11].

Most mothers were between 19 and 34 years old (69%), had brown or black skin color (59.7%), and had more than 9 years of education (81.2%). Prenatal care was considered adequate (six or more visits) for 91.9% of women, the most common mode of delivery was Cesarean section (61.3%), and the most deliveries occurred in public hospitals (57.3%). The prevalence of low birth weight (< 2.500 g) was 8.1%. We found 2072 events of SMM in 2060 mothers (non-weighted population: 46 events in 42 mothers/survey cases), with a total SMM rate (SMMR) of 5.6% (Table 1). Studies investigating SMM and maternal near miss (MNM)—which is the most extreme group within the severe morbidity spectrum—have been mainly conducted in low income countries[19,20] because most maternal deaths occur in these countries. The objective of these studies was to identify cases and support programs to reduce maternal morbidity and mortality. It is noteworthy that this is a cross-sectional study with limitations to causal inference. Also, the main concern in our research was that it was based on information provided by the mothers, without access to medical records to confirm diagnoses and procedures, potentially leading to memory bias. Although we did take that into account, one of the study purposes was to use an easy and pragmatic approach to data collection that might be reproducible in any setting, regardless of technical and economic conditions.   Source:


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