Pregnancy complications in Brazilian puerperal women treated in the public and private health systems 1

ABSTRACT Objective: to analyze the prevalence of pregnancy complications and sociodemographic profile of puerperal patients with complications, according to the form of financing of the childbirth service. Method: cross-sectional study with interview of 928 puerperal women whose childbirth was financed by the Unified Health System, health plans and private sources (other sources than the Unified Health System). The sample was calculated based on the births registered in the Information System on Live Births, stratified by hospital and form of financing of the childbirth service. Data were analyzed using the chi-square and Fisher’s exact tests. Results: the prevalence was 87.8% for all puerperal women, with an average of 2.4 complications per woman. In the case of deliveries covered by the Unified Health System, urinary tract infection (38.2%), anemia (26.0%) and leucorrhea (23.5%) were more frequent. In turn, vaginal bleeding (26.4%), urinary tract infection (23.9%) and leucorrhoea (23.7%) were prevalent in deliveries that were not covered by the Unified Health System. Puerperal women that had their delivery covered by the Unified Health System reported a greater number of intercurrences related to infectious diseases, while women who used health plans and private sources reported intercurrences related to chronic diseases. A higher frequency of puerperal adolescents, non-white women, and women without partner among those assisted in the Unified Health System (p < 0.001). Conclusion: the high prevalence of complications indicates the need for monitoring and preventing diseases during pregnancy, especially in the case of pregnant women with unfavorable sociodemographic characteristics.


Introduction
Gestation is a physiological event in the women's life usually free from complications. However, hundreds of thousands of women die every year due to pregnancy and childbirth complications (1) .
Health problems during pregnancy have increased worldwide, mainly due to complex interactions between demographic factors and lifestyle, as well as advances in modern medicine (2) , with new diagnostic and therapeutic practices.
Among the main clinical pregnancy complications reported in the literature are Urinary Tract Infections (UTIs) (3)(4) , pregnancy-induced hypertension (PIH), anemia and hyperemesis (5)(6) . In the United States, a multicenter study of hospitalizations during pregnancy showed a 71% increase in the occurrence of PIH between 1994 and 2011 (7) . Another study also carried out in the United States pointed out that the main intercurrences associated with maternal mortality were pre-eclampsia and obstetric hemorrhage (8) .
Another common complaint in pregnancy are urinary tract infections (UTI), with well-known severity and frequency (9) . This complication represents one of the main risk factors for preterm birth and restriction of intrauterine growth, low birth weight and eclampsia (10) .
Anemia can occur in up to 19% of pregnant women worldwide according to estimates (11) and it is associated with low sociodemographic profiles, being more common in developing countries (12) .
Women with unfavorable socioeconomic levels, preexisting conditions such as diabetes, hypertension, anemia and heart disease, and adolescents or women over 35 years of age may be more likely to experience undesirable outcomes, since complications during pregnancy are predictors of maternal and fetal morbidity and mortality (13)(14) . It is estimated that, for each woman who dies during the gestation, another 20 to 30 experience acute or chronic complications, with permanent consequences that impair the body's functionality (15) . Intercurrences during pregnancy also affect the allocation of financial resources for maternal and child health. In the United States of America, a survey of 137,040 infants between 2007 and 2011 found a prevalence of 75.4% of women with at least one complication during the gestation period, increasing from US $ 987 to US $ 10,287 in the cost of care for newborns (16) .
In Brazil, many programs have been implemented for assistance, prevention and control of morbidity and mortality of women during pregnancy, childbirth and puerperium, especially at the national level, such as the Stork Network*, and state level, such as the Paranaense Mother Network in the State of Paraná ** .
However, these efforts have not fully achieved the expected goals. The Fifth Millennium Development Goal was to achieve a reduction of 75% in maternal mortality rates by 2015, but this was only 45% (1) worldwide, including in Brazil.
Knowing the prevalence, the main types of diseases and disorders and the sociodemographic characteristics  Only two puerperal women refused to participate in the study, because of wear due to long hospitalization since gestation; these women were replaced. An online form was used in the Google Docs app, which allows agility in both collecting and storing data in spreadsheets. During fieldwork, the spreadsheets were checked daily, aiming at the safety and quality of the data, if necessary further consultation of the medical records and contact with the puerperal women were performed.
For information on the complications, the women were first asked whether they had experienced any of the  As expected, the majority of women who had SUS births (91.6%) received prenatal care exclusively in the public network, whereas the majority of puerperal women with non-SUS births (99.5%) had prenatal care in the private or mixed network (Table 4).

Discussion
The high prevalence of pregnancy complications reported by the puerperae of Maringá, in the case of  was found, despite taking into account the differences in the socioeconomic profile of the population and in the form of data collection (17) .
In addition to the high prevalence of pregnancy and PIH, are in agreement with the literature (4,6) , but with different prevalence values. The most reported complication during pregnancy was higher than the expected mean, which is 20%*, the same as in a study conducted in Nigeria in 2011, in which a prevalence of 21% was found (18) .
Responsible for approximately 10% of antepartum hospitalizations, UTIs, sometimes asymptomatic, may progress to pyelonephritis and cystitis and trigger complications for the fetus, such as premature birth and low birth weight (9,15) . These complications can be avoided by care quality during pregnancy, diagnosis and early treatment, as recommended by national, state and municipal protocols for prenatal care (19) .  (20) . A study carried out in a hospital in Ethiopia in 2012 to analyze the prevalence and predictors of maternal anemia, there was a prevalence of 16.6% of anemia (21) , a lower value than that found in the present study. As a public health problem affecting low, middle and high income countries, the effects of anemia during pregnancy include low birth weight, some neurological diseases of the fetus and increased risk of maternal and perinatal mortality (20) . diagnostic tests and explanations that led them to report these occurrences. PMR occurs more frequently during the 24th to 26th week of pregnancy, and less frequently in the subsequent weeks (22) , and consists of the separation of the placenta implanted in the uterus (23) . In the present study, the highest frequency of PMR among women who had non-SUS births may be associated with the highest frequency ages above 35 years, a major risk factor for PMR* in this group.
PIH presented a higher incidence in this study than that found in a review with pregnant women from several countries of the world, which reported a incidence of 5.2 to 8.2% (24) . In this study, it was observed that the highest prevalence of PIH occurred among puerperal women who had non-SUS births, and the highest prevalence of gestational diabetes among those who had SUS births. is one of the complications with incidence of 5 to 10% in pregnant women*. PIH is considered a major cause of maternal morbidity and mortality in developing countries, with high rates of severe maternal morbidity and maternal mortality in Brazil (25) .
Other diseases reported in this study had a higher percentage among women who had SUS births, with also higher proportion of some infectious diseases such