Contribution of antepartum and intrapartum hemorrhage to the burden of maternal near miss and death in a national surveillance study.

OBJECTIVE: To evaluate the occurrence of severe obstetric complications associated with antepartum and intrapartum hemorrhage among women from the Brazilian Network for Surveillance of Severe Maternal Morbidity. DESIGN: Multicenter cross-sectional study. SETTING: Twenty-seven obstetric referral units in Brazil between July 2009 and June 2010. POPULATION: A total of 9555 women categorized as having obstetric complications. METHODS: The occurrence of potentially life-threatening conditions, maternal near miss and maternal deaths associated with antepartum and intrapartum hemorrhage was evaluated. Sociodemographic and obstetric characteristics and the use of criteria for management of severe bleeding were also assessed in these women. MAIN OUTCOME MEASURES: The prevalence ratios with their respective 95% confidence intervals adjusted for the cluster effect of the design, and multiple logistic regression analysis were performed to identify factors independently associated with the occurrence of severe maternal outcome. RESULTS: Antepartum and intrapartum hemorrhage occurred in only 8% (767) of women experiencing any type of obstetric complication. However, it was responsible for 18.2% (140) of maternal near miss and 10% (14) of maternal death cases. On multivariate analysis, maternal age and previous cesarean section were shown to be independently associated with an increased risk of severe maternal outcome (near miss or death). CONCLUSION: Severe maternal outcome due to antepartum and intrapartum hemorrhage was highly prevalent among Brazilian women. Certain risk factors, maternal age and previous cesarean delivery in particular, were associated with the occurrence of bleeding.

Severe maternal morbidity and near miss due to postpartum hemorrhage in a national multicenter surveillance study.

OBJECTIVE: To assess the occurrence of severe maternal complications owing to postpartum hemorrhage (PPH) and its associated factors. METHODS: A secondary analysis of data from a multicenter cross-sectional prospective surveillance study included 9555 cases of severe maternal morbidity at 27 centers in Brazil between July 2009 and June 2010. Complications of PPH, conditions of severity management, and sociodemographic and obstetric characteristics were assessed. Factors independently associated with severe maternal outcome (SMO) were identified using multiple regression analysis. RESULTS: Overall, 1192 (12.5%) of the 9555 women experienced complications owing to PPH (981 had potentially life-threatening conditions, 181 maternal near miss, and 30 had died). The SMO ratio was 2.6 per 1000 live births among women with PPH and 8.5 per 1000 live births among women with other complications. Women with PPH had a higher risk of blood transfusion and return to the operating theater than did those with complications from other causes. Maternal age, length of pregnancy, previous uterine scar, and cesarean delivery were the main factors associated with an increased risk of SMO secondary to PPH. CONCLUSION: PPH frequently leads to severe maternal morbidity. A surveillance system can identify the main causes of morbidity and could help to improve care, especially among women identified as being at high risk of PPH.

The prevalence of perinatal depression and its associated factors in two different settings in Brazil.

BACKGROUND: The prevalence of antepartum and postpartum depression (PPD) and its association with certain risk factors was evaluated. METHOD: The Edinburgh Postnatal Depression Scale (EPDS) was applied and sociodemographic data was obtained at the beginning of the third trimester of pregnancy and at 4-6 weeks postpartum. RESULTS: The prevalence of depression was 24.3% during pregnancy (n=600 women) and 10.8% in the postpartum period (n=555). The factors independently associated with antepartum depression were the absence of a partner (PRadj 1.93; 95%CI: 1.44-2.58), a lower socioeconomic class (1.75; 1.18-2.60), being non-white (1.48; 1.09-2.01) and multiparity (1.32; 1.01-1.74). For postpartum depression, the factors were the occurrence of psychological violence (PRadj 3.31; 95%CI: 2.02-5.43), use of alcohol during pregnancy (2.14; 1.33-3.45), being non-white (1.85; 1.11-3.08) and physical violence (2.14; 1.13-4.08). The sensitivity of depression during pregnancy as a predictor of PPD was 75%, while specificity was 81%. There were no differences between the two settings. LIMITATIONS: EDPS does not diagnose depression and as a screening instrument it could overestimate the true prevalence of depression. CONCLUSIONS: The use of the EPDS instrument during pregnancy would allow a screening for identifying women at higher risk of developing PPD and then a proposal of specific interventions to manage this condition. Postpartum depression was prevalent in around 10% of the women and was associated with unfavorable sociodemographic conditions including the use of alcohol and with the occurrence of psychological and physical violence.

Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil.

OBJECTIVE: To evaluate the reported occurrence of spontaneous and induced abortion, and abortion-associated severe maternal morbidity in Brazil. METHODS: A secondary analysis of the 2006 Brazilian Demographic Health Survey was conducted. Interview data on women's experience of spontaneous/induced abortion and associated factors were analyzed overall and by geographic region. Multinomial logistic regression was performed to identify factors independently associated with abortion. The risk of associated severe maternal morbidity was estimated. RESULTS: The reported lifetime rates of spontaneous and induced abortion were 13.3% and 2.3%, respectively, and were highest in the north (4.3%) and northeast (3.5%). The rate of spontaneous abortion was higher among women aged 40-49 years (odds ratio [OR] 1.15; 95% confidence interval [CI], 1.03-1.30) and among those with 0 or 1 children or delivery (OR 1.97; 95% CI, 1.36-2.85 vs OR 1.98; 95% CI, 1.37-2.86). Induced abortion was not associated with sociodemographic factors. Abortion significantly increased the risk of complications (hemorrhage and infection). CONCLUSION: Spontaneous abortion was significantly associated with parity and maternal age. Abortion in general carried a higher risk of severe maternal complications.