Resumo Objetivo Avaliar o efeito da utilização de unidades de terapia intensiva (UTIs) na mortalidade materna (MM) entre mulheres com morbidade materna grave (MMG). Materiais e Métodos Foi realizada uma análise secundária de um estudo transversal de vigilância de morbidade materna grave em 27 centros de referência obstétrica no Brasil. O foco desta análise foi a associação entre a utilização de UTI e morte materna segundo características individuais e condições de gravidade. Análises múltiplas considerando as variáveis uso de UTI, idade, etnia, adequação do cuidado e índice de desenvolvimento humano foram realizadas para identificar os fatores associados à morte materna e near-miss materno. Resultados Dos 82.388 partos ocorridos durante o período de estudo, 9.555 (11,6%) mulheres apresentaram MMG, e a razão de MM foi de 170,4/100 mil nascidos vivos. Neste grupo, 8.135 (85,1%) pacientes foram atendidas em instituições com disponibilidade de leitos de UTI, mas apenas 2.059 (25,3%) foram de fato admitidas em leitos de UTI. Na análise de regressão multivariada, quando se considerou a gravidade do caso pelo maternal severity score (pontuação de severidade materna, MMS, na sigla em inglês), houve uma grande redução da força de associação entre utilização de UTI e morte materna, além da inadequação do cuidado e não disponibilidade de UTI na instituição. Na avaliação considerando apenas os casos de maior gravidade (desfecho materno grave, DMG), observou-se o mesmo padrão de associação entre UTI e MM. Nos modelos utilizados, apenas a inadequação do cuidado e o MSS apresentam associação significativa com a MM. Conclusão O presente estudo aponta que as principais variáveis associadas à morte materna são a gravidade e a adequação do manejo do caso, mais frequentes nas internações em UTI. A utilização dos leitos de UTI sem a estratificação da gravidade da paciente pode não trazer benefícios esperados para uma parte das mulheres.

Abstract Objective To assess the use of the intensive care unit (ICU) and its effect on maternal mortality (MM) among women with severe maternal morbidity (SMM). Materials and Methods A secondary analysis of a cross-sectional study on surveillance of SMM in 27 Brazilian obstetric referral centers. The analysis focused on the association between ICU use and maternal death according to individual characteristics and disease severity. Two multivariate regressions considering use of the ICU, age, ethnicity, adequacy of care and the human development index were performed to identify the factors associated to maternal death and maternal near-miss. Results Out of 82,388 deliveries during the period, there were 9,555 (11.6%) women with SMM, and the MM ratio was of 170.4/100 thousand live births. In total, 8,135 (85.1%) patients were managed in facilities in which ICUs were available; however, only 2,059 (25.3%) had been admitted to the ICU. On the multivariate analysis, when the severity of the maternal disease was measured by the maternal severity score (MMS), the strength of the association between the use of the ICU and maternal death was greatly reduced, along with inadequate care and non-availability of the ICU at the facility. On the assessment of only the more critical cases (SMO, severe maternal outcome), the same pattern of association between ICU and MM was observed. In the models used, only inadequate care and MSS were significantly associated with MM. Conclusion The current study indicates that the main variables associated with maternal death are the severity and adequacy of the case management, which is more frequent in ICU admissions. The use of the ICU without the stratification of the patients by severity may not produce the expected benefits for part of the women.

Resumo 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.

Abstract 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 independentlyassociatedwithworseresultsintheindirectcausesgroup.Someprocedures 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.

OBJECTIVES: The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria. METHODS: In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals. RESULTS: Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially lifethreatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths). CONCLUSIONS: Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.