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

Silva, Josy Maria de Pinho da; Fonseca, Sandra Costa; Dias, Marcos Augusto Bastos; Izzo, Aline Silva; Teixeira, Gabrielle Pires; Belfort, Pamela Pinto

doi:10.1590/1806-93042018000100002

Josy Maria de Pinho da Silva

Instituto de Saúde Coletiva. Universidade Federal Fluminense. Rua Marques de Paraná, 303 - Anexo - 3° andar. Niterói, RJ, Brasil. CEP: 24030-215. E-mail: josy.m.pinhos@gmail.com

Sandra Costa Fonseca

Instituto de Saúde Coletiva. Universidade Federal Fluminense. Rua Marques de Paraná, 303 - Anexo - 3° andar. Niterói, RJ, Brasil. CEP: 24030-215. E-mail: josy.m.pinhos@gmail.com

Marcos Augusto Bastos Dias

Instituto Nacional de Saúde da Mulher, da criança e do adolescente Fernandes Figueira. Rio de Janeiro, RJ, Brasil.

Aline Silva Izzo

Instituto de Saúde Coletiva. Universidade Federal Fluminense. Rua Marques de Paraná, 303 - Anexo - 3° andar. Niterói, RJ, Brasil. CEP: 24030-215. E-mail: josy.m.pinhos@gmail.com

Gabrielle Pires Teixeira

Instituto de Saúde Coletiva. Universidade Federal Fluminense. Rua Marques de Paraná, 303 - Anexo - 3° andar. Niterói, RJ, Brasil. CEP: 24030-215. E-mail: josy.m.pinhos@gmail.com

Pamela Pinto Belfort

Instituto de Saúde Coletiva. Universidade Federal Fluminense. Rua Marques de Paraná, 303 - Anexo - 3° andar. Niterói, RJ, Brasil. CEP: 24030-215. E-mail: josy.m.pinhos@gmail.com

Author and year of article	Study location	Studied Period	Type of study/ source/ analysis	Population	Criteria	Results
Souza et al.⁹9 Souza JPD, Cecatti JG, Parpinelli MA. Fatores associados à gravidade da morbidade materna na caracterização do near miss. Rev Bras Ginecol Obstet. 2005; 27 (4): 197-203. 2005	Campinas, Sao Paulo	From July 2003 until June 2004	-Case-control -Bivariate analysis	- 1 24 women with severe maternal morbidity at a University maternity	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. or Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. -Additional: Geller et al.³³33 Geller SE, Rosenberg D, Cox SM, Kilpatrick S. Defining a conceptual framework for near miss maternal morbidity. J Am Med Womens Assoc. 2002; 57 (3): 135-9.	-Severe maternal morbidity (SMM): 124 cases (Mantel or Waterstone criteria). SMM ratio: 42/1,000 childbirths -Near miss ratio (Geller³³33 Geller SE, Rosenberg D, Cox SM, Kilpatrick S. Defining a conceptual framework for near miss maternal morbidity. J Am Med Womens Assoc. 2002; 57 (3): 135-9. criteria): 6,8/1,000 childbirths; 20 women with very severe maternal morbidity (Cases) and 104 controls "with others severe morbidities" (Control) - Previous abortion was the only association with SMM (OR=3.41 ; 95%CI=1.08-10.79). -Hypertension was the only clinical condition most frequent for SMM, while hemorrhage predominated on the near miss group
Souza et al.¹⁰10 Souza JP, Cecatti JG, Parpinelli MA, Serruya SJ, Amaral E. Appropriate criteria for identification of near miss maternal morbidity in tertiary care facilities: a cross sectional study. BMC Pregnancy Childbirth. 2007; 11 (7): 20. 2007	Campinas, Sao Paulo	From July 2003 until June 2004	-Cross-sectional descriptive -Daily visits: delivery rooms, ICU, Ward. Review on medical files after hospital leave.	- 2929 childbirths in a university maternity	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. or Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93.	-Total: 124 cases of SMM (SMM ratio= 42/1000 childbirths). - 2 maternal deaths. MNM/MD ratio 62 - Waterstone's criteria= 86 (SMM ratio = 38/1000), which preeclampsia was the most frequent; - Mantel's criteria= 62 (SMM ratio= 31/1000), which ICU admission was the most frequent - Most common conditions= Hypertension (57.3%), non-obstetrics (21%) and hemorrhage (13.7%)
Amorim et al.¹¹11 Amorim MM, Katz L, Valença M, Araújo DE. Morbidade materna grave em UTI obstétrica no Recife, região nordeste do Brasil. Rev Assoc Med Bras. 2008; 54 (3): 261-6. 2008	Recife, Pernambuco	2003-2007	-Cross-sectional descriptive -Review on medical files	- 291 women with near miss criterion admitted in the obstetrics ICU	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90.	- Of the 291= hypertension (78.4%) was the main cause for admission, followed by hemorrhage - Most common clinical diseases: heart diseases (5.8%), chronic arterial hypertension (5.1%), chronic liver diseases (3%) and diabetes mellitus (2.4%) - Eclampsia was present in 38.8%, HELLP syndrome in 28,2% and hemorrhagic shock in 27.1% of the patients - Most common invasive procedures: blood transfusion (36%), profound venous puncture (13.4%), vasoactive drugs (1 0.8%) and assisted mechanical ventilation (9.1%)
Luz et al. ¹²12 Luz AG, Tiago DB, Silva JC, Amaral E. Severe maternal morbidity at a local reference university hospital in Campinas, São Paulo, Brazil. Rev Bras Ginecol Obstet. 2008; 30 (6): 281-6. 2008	Campinas, Sao Paulo	2005-2006	-Cross-sectional -Review on medical files -Non-adjusted prevalence ratio	- 2207 childbirths - 1 1 4 women with SMM	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. -Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93.	- SMM = 114 cases (15 of extremely severe morbidity ESMM and 99 of other morbidities) - ESMM rate= 6.8/1,000 childbirths; Rate of others maternal morbidities= 44.9/1,000 childbirths - Most common conditions of ESMM= post-childbirth hemorrhage (46.7%), insufficiency respiratory (13.4%), hypertension (13.3%) and pre-childbirth hemorrhage (13.3%); without any association with the variables in the study
Oliveira-Neto et al.,¹³13 Oliveira Neto AF, Parpinelli MA, Cecatti JG, Souza JP, Sousa MH. Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity. Int J Gynaecol Obstet. 2009; 105 (3): 252-6. 2009	Campinas, Sao Paulo	2002-2007	-Retrospective cohort -Bivariate analysis	- 673 women in the ICU obstetric at the University maternity	-ICU admission	- Of the 673 women, 18 cases of MD and 655 of SMM. - SMM ratio = 46.6/1,000 LB; MMR=124/100,000 LB -Causes of MNM and SMM/MD ratio= Hypertension: 322 cases, ratio 321:1 / Hemorrhage: 92 cases, ratio 30:1 / Infections: 17 cases, ratio 6:1 Non-obstetrics: 230 cases, ratio 25:1 -Interventions/procedures associated to death: reanimation, mechanical ventilation, vasoactive drugs use, cardioversion, blood transfusion
Amaral et al.,¹⁴14 Amaral E, Souza JP, Surita F, Luz AG, Sousa MH, Cecatti JG, Campbell O. A population-based surveillance study on severe acute maternal morbidity (near miss) and adverse perinatal outcomes in Campinas, Brazil: the Vigimoma Project. BMC Pregnancy Childbirth. 2011; 11:9. 2011	Campinas, Sao Paulo	From October 2005 until December 2005	-Cross-sectional descriptive -Daily collection of medical files and hospital registration -MD committee evaluation	-All cases of severe acute maternal morbidity/ near miss in the city. - 4,491 live births	-Mantel' et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. adapted criteria -Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93.	- MNM total cases= 95 / Maternal death total = 4 MNM ratio= 21.2/1,000 live births MNM/MD ratio= 23.7:1; mortality rate= 4.04% - Causes= hypertension diseases (57.8%); post-childbirth hemorrhage (17.9%) - Delays for care= 34% of the cases (most frequent after admission in maternities, in relation to management, like the use of magnesium sulfate and post-childbirth hemorrhage prophylaxis)
Morse et al.,¹⁵15 Morse ML, Fonseca SC, Gottgtroy CL, Waldmann CS, Gueller E. Morbidade Materna Grave e Near Miss em Hospital de Referência Regional. Rev Bras Epidemiol. 2011; 14 (2): 310-22. 2011	Niteroi, Estado do Rio de Janeiro	2009	-Cross-sectional descriptive -Review on medical files	- 1.554 childbirths in a referral public maternity hospital for, high-risk in the metropolitan region II of Rio de Janerio	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. -Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. -WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- MNM cases, considering any criteria: 89 cases; by WHO criteria, 10 cases. Three cases of MD - MNMR= - WHO - 9.4/1,000 live births; Waterstone - 81.4/1,000 live births; - Mantel - 13.1/1,000 live births -Mortality rate (WHO) = 23%; MNM/MD ratio = 3.3 Most frequent markers were: severe preeclampsia (68.5%), severe hemorrhage (19.1%) and ICU admission (10.1%)
Moraes et al.,¹⁶16 Moraes AP, Barreto SM, Passos VM, Golino PS, Costa JA, Vasconcelos MX. Incidence and main causes of severe maternal morbidity in São Luís, Maranhão, Brazil: a longitudinal study. São Paulo Med J. 2011; 129 (3): 146-52. 2011	Sao Luiz, Maranhao	2009-2010	-Longitudinal descriptive -Search on medical files and interviews with health professionals at the health units -Fisher test, χ², t -Stude nt tes t a nd Mann-Whitney	- 8493 childbirths	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. -Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93.	- 127 women presented one of the analyzed criteria -Incidence rate of severe maternal morbidity= Total: 15/1,000 childbirths; Waterstone: 14.1/1,000 childbirths Mantel: 3.4/1,000 childbirths - At admission, 84% of the women presented hypertension disorders, 11.4% hemorrhagic disorders, 2.5% infected abortion and 1.6% other causes -Significant association with ESMM cases: longer hospitalization time (p-value = <0.001) e hemorrhage (p-value = <0.01)
Lotufo et al.,¹⁷17 Lotufo FA, Parpinelli MA, Haddad SM, Surita FG, Cecatti JG. Applying the new concept of maternal near miss in an intensive care unit. Clinics. 2012; 67 (3): 225-30. 2012	Limeira, Sao Paulo	2004-2007	-Cross-sectional -Multivariate regression	- 158 wo men a d m it-ted at an obstetric ICU at a general teaching hospital	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011. -ICU admission	ICU admission immediately after childbirth (87%) - From the total, 5 MD, 43 MNM, 110 PLTC - MNM ratio= 4.4/1,000 live births; Mortality rate=10.6% (higher for clinical-surgical conditions and infections) - MNM/MD= 8.6 - Most common management criteria, outlining vasoactive drugs, hysterectomy and blood transfusion; among the laboratory, the PaO2/Fio2<200 ratio was the most present and, among the clinical criteria, shock. - The only association between MNM and MD: cesarean section (OR=0.03; CI=0.002-0.49)
Moraes et al.,¹⁸18 Moraes APP, Barreto SM, Passos VM a, Golino PS, Costa JE, Vasconcelos MX. Severe maternal morbidity: a case-control study in Maranhão, Brazil. Reprod Health. 2013; 10:11. 2013	Sao Luiz, Maranhao	2009-2010	-Case-control -Health professionals' report	-Two high-risk maternities and two referral obstetric ICU - 122 MNM cases at the ICU and 244 controls (maternities)	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. -Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93.	Total of cases: 122 - 66.4% presented severe pre-eclampsia, 11.5% eclampsia, 11.4% obstetric hemorrhage, 5.7% HELLP syndrome, 2.5% infected abortion, 1.6% preeclampsia overlapped chronic hypertension and 1.6% obstetrics complications - Statistically significant association with SMM: age ≥35 years old (OR=3.11), previous hypertension (OR=2.52), < 4 prenatal consultations (OR=1.89)
Lobato et al.,¹⁹19 Lobato G, Nakamura-Pereira M, Mendes-Silva W, Dias MAB, Reichenheim ME. Comparing different diagnostic approaches to severe maternal morbidity and near miss: a pilot study in a Brazilian tertiary hospital. Eur J Obstet Gynecol Reprod Biol. 2013; 167 (1): 24-8. 2013	Rio de Janeiro, Estado do Rio de Janeiro	2008	-Cross-sectional descriptive -Review on medical files	- 1,163 women in University maternity hospital	-Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. -WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011. -Reichenheim et al.,⁴4 Reichenheim ME, Zylbersztajn F, Moraes CL, Lobato G. Severe acute obstetric morbidity (near miss): a review of the relative use of its diagnostic indicators. Arch Gynecol Obstet. 2009; 280 (3): 337-43. 2009 criteria	Total of cases (considering any criteria): 157 - MNMR were: 33.2/1,000 live births by WHO; 155.2/1,000 live births by Waterstone 188.4/1,000 live births by Reichenheim criteria 2009 - 2.3% of the cases presented WHO criteria, 10.8% Waterstone criteria and 13.2% Reichenheim criteria 2009 - From 27 cases of WHO, 77.8% were positive in other classification, 14.8% were exclusive of WHO (thrombocytopenia) - From 25 cases classified as exclusively by Reichenheim 2009, 80% presented severe hypertension, 68% were admitted to ICU, 20% received blood transfusion, 4% had pulmonary edema and 4% developed hemorrhage - The cases classified by Reichenheim 2009 and by Waterstone (105), 94.3% were pre-eclampsia, eclampsia and HELLP syndrome
Oliveira & Costa,²⁰20 Oliveira LC, Costa AAR. Óbitos Fetais e Neonatais entre Casos de Near Miss Materno. Rev Assoc Med Bras. 2013; 59 (5): 487-94. 2013	Recife, Pernambuco	2007-2010	-Cross-sectional descriptive -Review on medical files	-Maternities and obstetric ICU admissions at a tertiary public unit - 19,940 live births and 2,997 ICU admissions	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	Near miss cases= 255 - MNMR= 12.8/1,000 live births - Hypertensions disorders occurred in 62.7%, mainly severe pre-eclampsia (49%) and eclampsia (13.7%) - The most frequent infection was endometritis (25.1%), followed by pneumonia (19.6%) - 35.3% of postpartum hemorrhage was also identified - Laboratory criteria was present in 59.6% of the participants, while clinical and management criteria occurred in 50.2% and 49%, respectively.
Amorim et al.,²¹21 Amorim MM, Katz L, Barros AS, Almeida TS, Souza AS, Faúndes A. Maternal outcomes according to mode of delivery in women with severe preeclampsia: a cohort study. J Matern Fetal Neonatal Med. 2014; 28 (6): 654-60. 2014	Recife, Pernambuco	2008-2009	-Cohort -Bivariate analysis: RR complication according to the type of childbirth -Multivariate analysis: OR of complication according to the type of childbirth	- 500 severe preeclampsia patients, without other clinical conditions, admitted at a tertiary hospitals	-PLTC	- Global PLTC according to the type of childbirth: cesarean section -54% and vaginal - 32.7% - Conditions associated to cesarean section in women with severe preeclampsia: RR (95%CI) - Post-childbirth hemorrhage: RR=9.8 (2.4-39.9) -Hypertensive crisis: 1.58 (1.22-2.06) - Associated factors with PLTC in 500 women: Cesarean section - OR=1,91 (1.52-4.57) Pre-childbirth HELLP syndrome- OR=3.91 (1.55-9.88)
Galvao et al.,²²22 Galvão LP, Alvim-Pereira F, de Mendonça CM, Menezes FE, Góis KA, Ribeiro RF, Gurgel RQ. The prevalence of severe maternal morbidity and near miss and associated factors in Sergipe, Northeast Brazil. BMC Pregnancy Childbirth. 2014; 14: 25. doi:10.1186/1471-2393-14-25 https://doi.org/10.1186/1471-2393-14-25... 2014	Sergipe	2011-2012	-Case-control incidence -Medical files, prenatal care cards and interviews	-Two referral maternities for the whole State -16,243 live births	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-Total of SMM (or PLTC): 1,102 cases -Near miss cases: 77/Maternal deaths: 17 - MNMR: 4.7/1,000 live births; SMMR: 67.8/1,000 live births - Mortality rate: 18%; MNM/MD ratio=4.5 - Most frequent morbidities: 67.5% hypertensive disorders, 15.4% hemorrhagic disorders and 61.7% one of the critical interventions defined by WHO; - Most frequent criteria: 87.1% £1 management criteria, 41.4% ≥1 clinical criteria and 21.4% ≥1 laboratorial criteria - Statistically significant association to near-mis: previous abortion (OR=2.68), previous cesarean section (OR=1.64) and current (2.36) and conscience alteration (OR=15.18)
Menezes et al.,²³23 Menezes FE, Galvão LP, de Mendonça CM, Góis KA, Ribeiro RF Jr, Santos VS, Gurgel RQ. Similarities and differences between WHO criteria and two other approaches for maternal near miss diagnosis. Trop Med Int Health. 2015; 20 (11): 1501-06. 2015	Sergipe	2011-2012	-Cross-sectional descriptive -Hospital files	- 20,435 women admitted in two maternities , 1 ,196 with potential life threatening conditions (PLTC)	-Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. -WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011. -Reichenheim et al.⁴4 Reichenheim ME, Zylbersztajn F, Moraes CL, Lobato G. Severe acute obstetric morbidity (near miss): a review of the relative use of its diagnostic indicators. Arch Gynecol Obstet. 2009; 280 (3): 337-43. 2009 criteria	- MNMR= Reichenheim et al.⁴ 2009= 59/1,000 LB Waterstone et al.³¹= 24.8/1,000 LB WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.= 4.7/1,000 LB - 6.4% of the cases were compatible with WHO criteria, 33,8% compatible with Waterstone and 80,2% compatible with Reichenheim 2009 - Of the 77 WHO cases, 4 were exclusive, 72 were positive also by Reichenheim 2009 and 37 also positive by Waterstone; - The most frequent criteria according to Reichenheim 2009 were: 54.8% severe hypertension, 28.3% blood transfusion and 7.5% ICU admission - The most frequent criteria according to Waterstone were: 71.6% severe pre-eclampsia, 13% eclampsia and 7.6% HELLP syndrome
Pacheco et al.,²⁴24 Pacheco AJ, Katz L, Souza AS, de Amorim MM. Factors associated with severe maternal morbidity and near miss in the São Francisco Valley, Brazil: a retrospective, cohort study. BMC Pregnancy Childbirth. 2014; 14: 91. 2014	Vale de Sao Francisco, Pernambuco	2011	-Retrospective cohort -Prenatal care cards, medical files -Multivariate analysis -Logistic regression	- 2,291 women	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- 400 (17.5%) of severe maternal morbidity cases and 24 (1.1%) cases with one or more criteria of maternal near miss were identified - Association to severe maternal morbidity and/or maternal near miss= previous history on cesarean section (RR:1.43), presence of chronic hypertension (RR:6.78), current cesarean section (OR:2.6), presence of comorbidity (OR:3.4) and less than 6 pre-natal consultation (OR:1.13)
Souza et al.,²⁵25 Souza MAC, Souza TH, Gonçalves AK. Fatores determinantes do near miss materno em uma unidade de terapia intensiva obstétrica. Rev Bras Ginecol Obstet. 2015; 37 (11): 498-504. 2015	Natal, Rio Grande do Norte	2013-2014	-Cross-sectional -Review on medical files - χ² tes ts	- 492	-Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. -Geller et al.³³33 Geller SE, Rosenberg D, Cox SM, Kilpatrick S. Defining a conceptual framework for near miss maternal morbidity. J Am Med Womens Assoc. 2002; 57 (3): 135-9.	- There were more near miss cases when woman presented= 1) hypertensive disorders (50.0%); 2) severe sepsis (23.8%); 3) severe hemorrhage (21.4%) - Clinical conditions with significant relative risk for MNM: first childbirth (OR=3.1), hypertensive gestational disorders (OR=8.0) and cesarean section (OR=39.2)
Oliveira & Costa,²⁶26 Oliveira LC, Costa AAR. Near miss materno em unidade de terapia intensiva: aspectos clínicos e epidemiológicos. Rev Bras Ter Intensiva. 2015; 27 (3): 220-7 2015	Recife, Pernambuco	2007-2010	-Cross-sectional descriptive -Review on medical files	- 2,997	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- MNMR: 12.8/1,000 LB -The main disorders presented were: hypertensive, hemorrhagic and infectious -Among the hypertensive disorders cases: 42.3% severe pre-eclampsia, 13.7% eclampsia and 6.7% gestational aggravated chronic hypertension; HELLP syndrome in 41.2% of the participants - 59.6% presented one or more laboratorial criteria, 50.2% presented one or more clinical criteria and 49% presented one or more of management criteria - Clinical and laboratorial criteria appeared mostly during pregnancy (42.2 clinical and 57.9% laboratorial), while the management criteria occurred mainly in postpartum (45.6%)
Madeiro et al.²⁷27 Madeiro AP, Cronemberger AR, Lacerda EZG, Brasil LG. Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piauí, Brazil. BMC Pregnancy and Childbirth. 2015, 15: 210. 2015	Teresina, Piauí	2012-2013	-Cross-sectional descriptive -Review on medical files -Multivariate analysis	- 5,841	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- MNMR: 9.6/1,000 LB; - SMMR: 11.3/1,000 LB - MNM/MD ratio: 5.6:1; - Mortality rate: 15.2% - Main determinants of severe maternal morbidity (near miss) and maternal death: hypertension (86.1%), hemorrhage (10%) and infectious diseases (2.9%). Severe pre-eclampsia, eclampsia and HELLP syndrome were the main causes of maternal near miss -Association with MNM: caesarean section (OR=6.2) and " 5 days hospitalization (OR=6.7)
Barbosa et al.,²⁸28 Barbosa IRC, Silva WBM, Cerqueira GSG, Novo NF, Almeida FA, Novo JLVG. Maternal and fetal outcome in women with hypertensive disorders of pregnancy: the impact of prenatal care. Ther Adv Cardiovasc Dis. 2015; 9 (4): 140-6. 2015	Sorocaba, Sao Paulo	4 anos (nao informado)	-Retrospective cohort	- 1,501 women in a referral hospital: Chronic arterial hypertension (564), pre-eclampsia (579), eclampsia (74) and pre-eclampsia / eclampsia overlapping chronic arte-rial	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- MNM R of all hypertensive = 5,4/1,000 LB - MNM highest ratio for isolated or overlapping eclampsia, - MNM lowest ratio for chronic hypertension and pre-eclampsia. Prenatal and maternal near miss association: (p< 0,01): - " 6 consultations: MNMR=3.05/1,000 LB - < 6 consultations: MNMR =8.27/1,000 LB - Without prenatal care: MNMR=9.48/1,000 LB
Ferreira etal.,²⁹29 Ferreira EC, Pacagnella RC, Costa ML, Cecatti JG. The Robson ten-group classification system for appraising deliveries at a tertiary referral hospital in Brazil. Int J Gynaecol Obstet. 2015a; 129 (3): 236-9. 2015	Campinas, Sao Paulo	2009-2013	-Cross-sectional descriptive -Review on medical files	- 12,771 women admitted at a referral University hospital	-ICU admission	-Near miss incidence: 50.5/1,000 childbirths -Vaginal section: 16/1,000 childbirths -Cesarean section: 91/1,000 childbirths -OR cesarean and near miss association: 6.24 (95% CI 5.06-7.69)
Vidal et al.,³⁰30 Vidal, CE, Carvalho MAB, Grimaldi IR, Reis MC; Baêta MCN, Garcia RB, Silva SAR. Morbidade materna grave na microrregião de Barbacena/MG. Cad Saúde Coletiva. 2016; 24 (2): 131-8. 2016	Barbacena, Minas Gerais	2014 (Feb-Aug)	-Case-control -Interview and medical files	- 92 cases and 1 84 controls -Santa Casa Maternity (SUS)	-Life threatening conditions	-MNM indicators not described. -Associated factors: previous hypertension - OR=14.3 (CI=4.5-45.5); cesarean section- OR=3.2 (1.6-6.3)

Author and year of the article	Study location	Studied period	Type of study/ source/ analysis	Population	Criteria	Results
Dias et al.⁵5 Dias MAB, Domingues RMSM, Schilithz AOC, Pereira MN, Diniz CSG, Brum IR, Martins AL, Theme Filha MM, Gama SGN, Leal MC. Incidência do Near Miss Materno no Parto e Pós-parto hospitalar: dados da pesquisa Nascer no Brasil. Cad Saúde Pública. 2014; 30 (Supl 1): S1-12. 2014	-Brazil	2011-2012	-"Born in Brazil" -Cross-sectional -Descriptive	- 23.940 puerperal had live birth or stillborn	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- MNM total of cases: 243 cases (23,747 cases estimation for the country) - MNM ratio: 10.2/1,000 live births - Among 243 women, most of them presented only one (67%) or two (20%) diagnostic criteria according to WHO - Most frequent criteria: clinical - respiratory frequency > 40 or < 6 per minute cycles; laboratorial - acute thrombocytopenia (platelets < 50,000); management - 5 or more red blood cell units transfusion
Domingues et al.,³⁴34 Domingues RM, Dias MA, Schilithz AO, Leal MD. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reprod Health. 2016; 13(Suppl 3): 115. 2016	-Brazil	2011-2012	-"Born in Brazil" -Cross-sectional -Multivariate lo-gistic regression	- 23.940 puerperal had live birth or stillborn	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- MNMR for women withoutt prenatal care: 27.9/1,000 LB - Women 35 years or more presented more clinical or obstetrics complications and had more elective cesarean sections and women with a previous cesarean section presented more complications during pregnancy -Association with maternal near miss = Prenatal care absence (OR:4.65;1.51-14.31), -Pilgrimage for 2 or more services (OR:4.49;2.12-9.52) -Obstetric complications (OR: 9.29; 6.69-12.90) -Type of childbirth: Elective cesarean section (OR:2.54; 1.67-3.88) and forceps (OR:9.37; 4.01-21.91)
Santana et al.,³⁷37 Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, Souza JP, Camargo RS, Pacagnella RC, Surita FG, Pinto e Silva JL. Brazilian Network for Surveillance of Severe Maternal Morbidity. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Gynaecol Obstet. 2012; 119 (1): 44-8. 2012	-Brazil -27 referral maternities in five regions	2009-2010	-"Multicenter stu-dy of the National Surveillance Network on Severe Maternal Morbi-dity" -Multicenter crosssectional -Multivariate analyses by Poisson regression	- Of the 9,555 women, 237 cases of abortion	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-Compared to the 9,318 other women, maternal near miss risk was higher in women who suffered abortion (PR=1.93; 1.12-3.31). -The WHO management criteria were more common in insecure abortion cases. - Factors associated to abortion complications: previous maternal conditions (sickle-cell anemia, low weight and neoplasia) and previous uterine scar
Giordano et al.,³⁹39 Giordano JC, Parpinelli MA, Cecatti JG, Haddad SM, Costa ML, Surita FG, Pinto e Silva JL, Sousa MH. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One. 2014; 9 (5): e97401. 2014	-Brazil - 27 referral maternities in five regions	2009-2010	"Multicen ter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analyses by Poisson regression for 321 cases with complete information.	-Of the 9,555 women, 6,280 had hypertensive diseases and 426 cases of eclampsia	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-Eclampsia prevalence: 5.2/1,000 LB - Specific MDR= 19.5/100,000 LB; Severe maternal outcomes (SMO) among 426 cases: MNM=70 and maternal death=16; - Mortality rate = 19% -Eclampsia indicators, according to Brazilian regions with the best IDH (South and Southeast) and the worse IDH (North, Northeast and Central-west), respectively: MNM ratio= 0.5/ 1,000LB and 1.2/1,000 LB MNM/MD = 3.4: 1 and 11:1; - Mortality rate = 22.6% and 8.33% Associated factors with SMO: Inadequate monitoring (PR =2.31 ; 1.48-2.59); any previous disease (PR=1.82; 1.26-2.64); sepsis (PR=2.75; 1.35-5.61)
Oliveira Jr et al.³⁶36 Oliveira Jr FC, Surita FG, Pinto e Silva JL, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Pacagnella RC, Sousa MH, Souza JP. Severe maternal morbidity and maternal near miss in the extremes of reproductive age: results from a national cross-sectional multicenter study. BMC Pregnancy Childbirth. 2014; 14: 77. 2014	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analyses by Poisson regression to evaluate factors related to severity (SMO vs PLTC) in two age groups	- 9,555 had complication	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-Maternal near miss ratio for age groups and adjusted PR (95%CI) to SMO (MNM+MD), considering 20-34 years as reference: - 40-49 years old: 31.4/1,000 LB; PR=1.52 (1.19-1.93); 35-39 years old: 17.5/1,000 LB; PR=1.19 (1.00-1.41); 20-34 years old: 8.39/1,000 LB; 10-19 years old: 7.14/1,000 LB; PR=0.89 (0.77-1.04)-Other factors statistically associated to SMO: In the 35-49 age group: age (PR=1.25); prenatal care at another service (PR=1.28); any delay on care (PR=2.03); previous morbidities (PR=2.23); infection (PR=4.71 ); surgical conditions (PR=3.94); hemorrhage (PR=3.06). Obesity (PR=0.59) and absent partner (PR=0.52) were protectors In the 10-19 age group: prenatal care at another service (PR=1.28); any delay on care (PR=2.11); previous morbidities (PR=2.03); infection (PR=5.23); surgical conditions (PR=4.58); hemorrhage (PR=2,75); nonwhite skin color (PR=1,36). Obesity (PR=0.52) -Adolescents had less hemorrhage and more delay on care. In the 10-14 age group, a MNM/MD ratio was very low
Pacagnela et al.,⁴⁶46 Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, Souza JP, Pattinson RC. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth. 2014; 5 (14): 159. 2014	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analyses by Poisson regression to evaluate factors related to the delay	- 9,555 had complication	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-Delays on obstetric care: 58% of some kind;- Related to Users: 10.2% -Access related: 34.6% (Most frequent in the 9,555 women - absence or inappropriate prenatal care); - Management quality related: 25.7% -Frequency according to severity: In the PLTC cases :52%, in the MNM cases: 68%; in maternal deaths: 84% - Increasing association between delay and severity, especially in management - 23.6% for PLTC, 42.3% for MNM and 65% for MD - Associated factors with delay: Adolescence (PR=1.09; 1.02-1.15); nonwhite skin color (PR=1.22; 1.07-1.39); low schooling (PR=1.45; 1.15-1.84), public hospital (PR=1.98; 1.40-2.79); absence of prenatal care (PR=1.66;1.26-2.19) and public prenatal care (PR =1.31; 1.03-1.67)
Rocha-filho et al.,³⁸38 Rocha Filho EA, Santana DS, Cecatti JG, Costa ML, Haddad SM, Parpinelli MA, Sousa MH, Camargo RS, Pacagnella RC, Surita FG, Pinto e Silva JL. Awareness about a life-threatening condition: ectopic pregnancy in a network for surveillance of severe maternal morbidity in Brazil. BioMed Res Int. 2014; 965724. 2014	-Brasil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analyses by Poisson regression to eva-l uate severity of the cases	- Of the 9,555 women , 312 had ectopic pregnancy cases (EP)	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-PLTC=286; MNM=25. MD =1 - MNM ratio= 0.3/1,000 LB; MNM/ MD ratio= 25:1; Mortality rate= 3.8% - There were no factors associated to severity
Zanette et al.,⁴⁰40 Zanette E, Parpinelli MA, Surita FG, Costa ML, Haddad SM, Sousa MH, Pinto e Silva JL, Souza JP, Cecatti JG. Brazilian Network for Surveillance of Severe Maternal Morbidity Group. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reprod Health. 2014; 11 (1): 4. 2014	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analyses by Poisson regression	- Of the 9,555 women, 6,315 had hypertensive disease	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- Severe hypertension was associated to 70% of hospital admissions. MNM cases= 349 cases - MNM ratio=4.2/1,000 LB; -MNM/MD ratio= 8.3:1; -Mortality rate = 10.7% - Most frequent management criteria: the use of magnesium sulfate (68.4%) - Most frequent complication: post-childbirth hemorrhage (4%) - Association to SMO: age ≥40 years old (PR=1.67; 1.21-2.31); nonwhite skin color (PR= 0.66; 0.48 - 0.91); absence of partner (PR= 0.53; 0.37-0.76); previous diseases (renal, cardiac and collagenases) with PR >4.0. Post-childbirth occurrence: PR= 11.82 (7.59 - 18.43); Elective cesarean section (1.75 1.11 - 2.76); abortion (2.63 1.05-6.59). Delays on care: services (2.86 1.89-4.33) and professionals (2.45 1.53-3.92)
Campanharo et al.,⁴⁵45 Campanharo FF, Cecatti JG, Haddad SM, Parpinelli MA, Born D, Costa ML, Mattar R; The Impact of Cardiac Diseases during Pregnancy on Severe Maternal Morbidity and Mortality in Brazil. PLoS One. 2015; 10 (12): e0144385. 2015	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Prevalence ratio adjusted by cluster effect	- Of the 9,555 women, 293 cases of cardiac diseases	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-Heart disease patients' profile: older, low weight, prenatal care at a public hospital, <37 weeks for admission. prolonged hospitalization time. PLTC= 235 cases; MNM= 44 cases MD= 14 cases MNMR= 0.5/1,000 LB; MNMR: MD= 3.1:1; Mortality rate= 24% -Predominant clinical (76%) and management (64%) criteria -Comparing women with heart disease and those without, as for SMO: PR=2.2 (1.7-2.8); MNM: PR=2.0 (1.3-3.2); MD: PR =3.7 (2.0-6.9);
Ferreira et al.,⁴⁷47 Ferreira EC, Costa ML, Cecatti JG, Haddad SM, Parpinelli MA, Robson MS. Robson Ten Group Classification System applied to women with severe maternal morbidity. Birth. 2015; 42 (1): 38-47. 2015	-Brazil -27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Descriptive	-Of the 9,555 women, those who had an abortion, ectopic pregnancy or missing data were excluded -Analysis of 7,247 puerperals	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	- PLTC and SMO according to Robson's classification (RTGCS): Global: SMO/PLTC=1:12. Groups with the worse performance-7.8.9.10 (presentation of anomalous, multiple pregnancy and prematurity) - Among the women who had cesarean: SMO/PLTC =1:11. Groups with the worse performance -7.8.9.10 and 3 (multiparas with cephalic single fetus >36 weeks) - Main causes: hypertension (77.4%) and hemorrhage (21.4%). In groups 3, 7 and 9 hemorrhage was >30%
Rocha Filho et al.⁴¹41 Rocha Filho EA, Costa ML, Cecatti JG, Parpinelli MA, Haddad SM, Sousa MH, Melo JR EF, Surita FG, Souza JP. Contribution of antepartum and intrapartum hemorrhage to the burden of maternal near miss and death in a national surveillance study. Acta Obstet Gynecol Scand. 2015; 94(1): 50-8. 2015	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analyses by Poisson regression	-Of the 9,555 women, analyses of 767 puerperals had hemorrhage before and during childbirth	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-PLTC: 613 cases; MNM:140 cases; MD:14 cases Mortality rate: 9% -Most common causes: premature placental abruption (50% of MNM and MD cases) -Among all women with SMO: 73 (52.1%) presented one of the clinical criteria. 45 (32.1%) presented one of the laboratorial criteria and 109 (77.9%) presented one of the management criteria - Associated factors with SMO: age (PR =1.03; 1.01-1.04) and previous cesarean section (PR =1.85; 1.28-2.66)
Rocha Filho et al.⁴²42 Rocha Filho EA, Costa ML, Cecatti JG, Parpinelli MA, Haddad SM, Pacagnella RC, Sousa MH, Melo Jr EF, Surita FG, Souza JP. Brazilian Network for Surveillance of Severe Maternal Morbidity Study Group. Severe maternal morbidity and near miss due to postpartum hemorrhage in a national multicenter surveillance study. Int J Gynaecol Obstet. 2015; 128 (2): 131-6. 2015	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Multivariate analysis by Poisson regression	- Of the 9,555 wo men , 1, 1 9 2 p uer-perals had post-childbirth hemorrhage	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	PLTC: 981 cases; MNM= 181 cases; MD= 30 cases; Mortality rate= 15% - Of all 181 MNM cases, 78.5% presented one of the management criteria. 54.7% presented one of the clinical criteria and 35.4% presented one of the laboratorial criteria - Associated factors with SMO= maternal age (PR= 1.03; 1.01-1.04); gestational age at admission (PR= 2.99; 1.76-5.07); cesarean section (PR= 2.31; 1.27-4.21); previous uterine scar (PR= 2.57; 1.07-6.17).
Cecatti et al.³⁵35 Cecatti JG, Costa ML, Haddad SM, Parpinelli MA, Souza JP, Sousa MH, Surita FG, Pinto e Silva JL, Pacagnella RC, Passini Jr R. Network for Surveillance of Severe Maternal Morbidity study Group. Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care. BJOG. 2016; 123 (6): 946-53. 2016	-Brazil -27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Descriptive	-All the 9,555 women	-WHO³3 Organização Mundial de Saúde. Avaliação da Qualidade do Cuidado nas Complicações Graves da Gestação: A Abordagem do Near Miss da OMS para a Saúde Materna. Uruguay. OMS; 2011.	-MNMR= 9.37/1,000 LB; MDR= 170/100,000; MNM/ MD ratio= 5.5:1; Mortality rate= 15.4% - Hemorrhage was the most frequent for MNM and MD, in comparison to PLTC; the same occurred for infection. Hypertension was more prevalent in PLTC and declined as the outcome became more severe - The most frequent Near miss criteria was management (58.3%) followed by clinical (50.3%) and laboratorial (50%) - In the presence of only 1 criteria, the. probability of MD was small and in the presence of 3 criteria, it was high -Indirect causes represented 46% of the maternal deaths.
Pfitscher et al.,⁴³43 Pfitscher LC, Cecatti JG, Pacagnella RC, Haddad SM, Parpinelli MA, Souza JP, Quintana SM, Surita FG, Costa ML. Brazilian Network for Surveillance of Severe Maternal Morbidity Group. Severe maternal morbidity due to respi-ratory disease and impact of 2009 H1N1 influenza A pandemic in Brazil: results from a national multicenter cross-sectional study. BMC Infect Dis. 2016a; 16: 220. 2016	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Two-dimensional analyses with adjusted prevalence ratio calculated	-Of the 9,555 women, 502 had severe infection	-WHO3	- PLTC cases: 255; MNM: 182; MD: 65 - MNMR= 2.2/1,000 LB; MNMR:MD= 2.8:1; Mortality rate of 26.3%. Among the 770 MNM cases. ¼ was sepsis -Statistically significant factors associated with SMO: Delay on care (PR= 1.93. 1.36-2.74); Spontaneous access (PR 0.42 0.29-0.59); Previous diseases (diabetes -PR =1.82; low weight -PR=2.17; cancer -PR =1.73 and drugs use- PR= 1.65)
Pfitscher et al.,⁴⁴44 Pfitscher LC, Cecatti JG, Haddad SM, Parpinelli MA, Souza JP, Quintana SM, Surita FG, Costa ML The role of infection and sepsis in the Brazilian Network for Surveillance of Severe Maternal Morbidity. Trop Med Int Health. 2016; 21 (2): 183-93. 2016	-Brazil - 27 referral maternities in five regions	2009-2010	-"Multicenter study of the National Surveillance Network on Severe Maternal Morbidity" -Two-dimensional analyses with adjusted prevalence ratio calculated	- Of the 9,555 women, 485 had severe respiratory disorder.	-WHO3	-206 were suspected of having H1N1 (49 confirmed). Confirmed cases had higher frequency of MNM -Mortality rate: 32.2% -Of the 770 MNM cases.¼ had respiratory diseases (44 were suspected of having H1N1 and 13 were confirmed) -Of the 49 women with H1N1, 13 were MNM and 14 had MD. - 55% of the women with respiratory disorders presented 3 or more near miss criteria and 24% just one criterion - Statistically significant factors associated with SMO: Age under 19 (PR= 0.73) and ≥35 (PR= 1.32); absence of partner (PR= 0.56); first pregnancy (PR= 0.65); previous cesarean section (PR=1.46); drug use (PR= 2.09); inadequate prenatal care (PR =0.75); private hospital (PR= 2.54); delay on care (PR= 1.74)

Author and year of the article	Study location	Studied period	Type of study/ source/ analysis	Population	Criteria	Results
Souza et al.,⁴⁸48 Souza JP, Souza MH, Parpinelli MA, Amaral E, Cecatti JG. Self-reported maternal morbidity and associated factors among Brazilian women. Rev Assoc Med Bras. 2008; 54 (3): 249-55. 2008	Brazil: seven locations - São Paulo, Rio de Janeiro, Minas Gerais and Espírito Santo, Midwest, South, Northeast and North regions	1996	-Survey - DHS 1996 -Household interviews in census sectors -Multivariate logistic regression	- 3,761 women had live births in the last five years - 5,045 LB	-Complications: Prolonged labor, excessive hemorrhage, high fever, seizures	-Presence of complications during pregnancy: 4.8% prolonged labor, 10.3% hemorrhage, 5.4% fever, 3.7% seizures: 2.7% - Significant association found with SMM: hemorrhage associated to non-white skin color (OR= 1,72); any complication associated to previous children (OR=1.33), and the North (OR=2.00) and Midwest (OR=1.33) regions
Souza et al.,⁴⁹49 Souza JP, Cecatti JG, Parpinelli M, Sousa MH, Lago TG, Pacagnella RC, Camargo RS. Maternal morbidity and near miss in the community: findings from the 2006 Brazilian demographic health survey. BJOG. 2010; 117 (13): 158692. 2010b	Brazil: five regions	2006-2007	-Survey - DHS 2006 -Household interviews in census sectors -Multivariate logistic regression	- 5,025 women had live births in the last five years - 5,045 LB	-Eclampsia, hysterectomy, blood transfusion and ICU admission	-Presence of complications during pregnancy: 2%. Most frequent: hemorrhage -Criteria: eclampsia - 0.6%; hysterectomy - 0.2%; blood transfusion -0.8% and ICU - 0.5%. - Population estimates: Number of maternal near miss cases: around 70,000 MNM Ratio: 21.1/1,000 LB MNM/MD Ratio=28.4; Mortality rate= 3.3% -Association with age 40-49 years old (OR=9.60) and low schooling (OR=2.18)
Oliveira Jr et al.,⁵⁰50 Oliveira Jr FC, Costa ML, Cecatti JG, Pinto e Silva JL, Surita FG. Maternal morbidity and near miss associated with maternal age: the innovative approach of the 2006 Brazilian demographic health survey. Clinics. 2013; 68 (7): 922-7. 2013	Brasil: cinco regioes	2006-2007	-Survey - DHS 2006 -Household interviews in census sectors -Multivariate logistic regression	- 5,025 women had live births in the last five years - 6,833 pregnancies	-Eclampsia, hysterectomy, blood transfusion and ICU admission	-Maternal near miss ratio by age: 15-19 years: 5.9/1,000 LB (most frequent: eclampsia) 20-34: 19.9/1,000 LB (most frequent: blood transfusion) 35-49; 28.3/1,000 LB (most frequent: eclampsia) -For age group of 35-49 years old, association with low schooling and pregnancy complications (OR=5.23)
Camargo et al.,⁵¹51 Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo EF Jr, Sousa MH. Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil. Int J Gynaecol Obstet. 2011; 112 (2): 8892. 2011	Brasil: cinco regioes	2006-2007	-Survey - DHS 2006 -Household interviews in census sectors	- 15,542 women who had an abortion	-Eclampsia; hemorrhage; infection ; hysterectomy; blood transfusion; ICU admission; mechanical ventilation	-Comparing women who had an abortion with those who had not, there was a higher prevalence of hemorrhage (PR= 2.54; 1.85-3.49); infection (PR= 2.89; 1.34-6.24); hysterectomy (PR= 5.37; 0.83-34.93), severe maternal morbidity (SMM) criteria. Global association abortion/SMM = 2.29 (1.73-3.04)
Cecatti et al.,⁵²52 Cecatti JG, Souza RT, Pacagnella RC, Leal MC, Moura EC, Santos LM. Maternal near miss among women using the public health system in the Amazon and Northeast regions of Brazil. Rev Panam Salud Pública. 2015; 37 (4-5): 232-8. 2015	-Amazonia and Northeast	2010	-Secondary analysis of the survey "Chamada Neonatal" performed during vaccination campaign -Poisson regression	- 13,044 women with childbirth history of previous year	-Eclampsia, hysterectomy, blood transfusion; ICU admission	- Maternal near miss ratio: 31.5/1,000 LB -Amazonia - 36.3/1,000 LB (higher in Roraima - 57.9/1,000 LB and lower in Rondonia - 6.7/1,000 LB); Northeast - 29.6/1,000 LB (higher in Alagoas and Pernambuco- about 40/1,000 LB and lower in Maranhao-16.3/1,000 LB) - Most frequent complication: hemorrhage and infection. - Most frequent MNM criteria: eclampsia and blood transfusion - Significant association with MNM: indigenous ethnicity (PR= 2.77), prenatal care at a public health service (PR=1.95), pregnancy pilgrimage (PR= 1.49) and cesarean childbirth (PR= 2.56).
Rosendo & Roncalli,⁵³53 Rosendo TM, Roncalli AG. Prevalência e fatores associados ao Near Miss Materno: inquérito populacional em uma capital do Nordeste Brasileiro. Ciênc Saúde Colet. 2015; 20 (4): 1295-304. 2015	-Natal, RN	2014	-Household survey Difference in proportions (Chi-square test)	- 848 (15-49 years old, reported pregnancy in the last five years) in 8,227 households	- Hysterectomy , blood transfusion, ICU admission and eclampsia (criteria proposed by Souza et al.,⁵⁴54 Sousa MH, Cecatti JG, Hardy EE, Serruya SJ. Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveil-lance. Reprod Health. 2008; 5: 6.)	- Maternal near miss ratio: 41.1/1,000 LB. -Most referred criteria identified: ICU admission (19.1/1,000 LB) and eclampsia (13.5/1,000 LB), followed by blood transfusion (11.3/1,000 LB), hysterectomy (2.3/1,000 LB). - Clinical conditions mostly reported: hemorrhage (10.7%) and urinary infection (10.7%); most frequent intervention: hospital stay >7 days postpartum (5.4%) - Increased prevalence of MNM in mixed/black women, although with significance border (p=0.052)

Author and, year of the article	Study location	Studied period	Type of study/ source/ analysis	Population	Criteria	Results
Sousa et al.,⁵⁴54 Sousa MH, Cecatti JG, Hardy EE, Serruya SJ. Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveil-lance. Reprod Health. 2008; 5: 6. 2008	Brazil (Brazilian capitals and the Federal District)	2002	-SIH and SIM -Descriptive	- 32,379 women with diagnosis of severe maternal morbidity	-Mantel et al.³²32 Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near miss. Br J Obstet Gynaecol. 1998; 105 (9): 985- 90. -Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93.	- MNMR was 44.4/1,000 LB - The most frequent maternal near miss criteria were: Severe pre-eclampsia (30.6%), Sepsis (23.7%) and Hemorrhage (20.3%)
Magalhães et al.,⁵⁷57 Magalhães MC, Bustamante-Teixeira MT. Morbi-dade materna extremamente grave: uso do Sistema de Informação Hospitalar. Rev Saúde Pública. 2012; 46 (3): 472-78. 2012	-Juiz de Fora, MG	2006-2007	-SIH -Prevalence ratio	- 8,690 hospitalized women with diagnosis from chapter XV of ICD-10 and/or obstetrics procedures	-WHO3	- The prevalence of Extremely Severe Maternal Morbidity was 37.8/1,000 women - The most frequent procedures/conditions were: blood transfusion (15.7/1,000), increased length of hospital stay (9.5/1,000) and severe pre-eclampsia/eclampsia (8.2/1,000) - Predicting factors for ESMM: hospital stay length higher than 4 days (PR= 14.32), more than one hospitalization (PR= 5.1) and stillbirth (PR= 4.86).
Nakamura-Pereira et al.,⁵⁸58 Nakamura-Pereira M, Mendes-Silva W, Dias MAB, Reichenheim ME, Gustavo Lobato. Sistema de In-formações Hospitalares do Sistema Único de Saúde (SIH-SUS): uma avaliação do seu desempenho para a identificação do near miss materno. Cad Saúde Pública. 2013; 29 (7): 1333-45. 2013	-Rio de Janeiro, RJ	2008	-SIH -Review on medical files -Descriptive	-221 cases	-WHO3	-MNMR: 33.2/1,000 LB - 58.8% of the women presented clinical conditions compatible to non-near miss maternal morbidity; 12.2% presented clinical condition compatible to near miss - The main determinants of near miss occurrence: hemorrhage (40.7%) and hypertensive syndrome (29.6%) - Most frequent clinical conditions: severe thrombocytopenia (40.7%), shock (37%) and creatinine >= 3.5 mg/mL (18.5%)
Rosendo & Roncalli,⁵⁵55 Rosendo TM, Roncalli AG. Near miss materno e ini-quidades em saúde: análise de determinantes contextuais no Rio Grande do Norte, Brasil. Ciênc Saúde Colet. 2016; 21 (1): 191-201. 2016	- 167 cities in Rio Grande do Norte, Brazil	2008 -2012	-Ecologic study -SIH -Multiple linear regression	-Women 15-49 years old, residents in RN, hospitalized for obstetrics procedures at SUS-hired or associated units. Cities grouped (Skater method) in 63 clusters.	Waterstone et al., ³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. excluding HELLP syndrome (for not having the corresponding ICD-10 code)	- MNMR average: 36.67/1,000 women (SD: 17.90). According to the markers condition, the higher ratio was for pre-eclampsia (24.66), hemorrhage (4.55) and sepsis (4.29). Hypertensive diseases: group with the highest average MNMR (27.65) - For MNMR, positive correlation with % households with high density (p=0.049) and % mothers head of the household with low schooling (p=0.032) and negative correlation with % of families benefited by "Bolsa Família" grant program (p=0.001) - For HYPDR: positive correlation with % households with high density (p=0,021); and negative correlation with % of families benefited by "Bolsa Família" grant program (p=0.001); for RH: positive correlation with child mortality (p=0.041) - Lack of variables correlation in primary healthcare as prenatal consultations and Family Health Strategy.
Silva et al.,⁵⁶56 Silva TC, Varela PLR, Oliveira RR, Mathias TAF. Morbidade materna grave identificada no Sistema de Informações Hospitalares do Sistema Único de Saúde, no estado do Paraná, 2010. Epidemiol Serv Saúde. 2016; 25 (3): 617-28. 2016	-Paraná	2010	-Descriptive -Source: SIH	- 111,409 women aged 10-49 years old hospitalized at SUS with pregnancy, childbirth and puerperium complications.	-Waterstone et al.³¹31 Waterstone M, Bewley S, Wolfe C. Incidence and predic-tors of severe obstetric morbidity: case-control study. BMJ. 2001;322(7294):1089-93. -Mantel et al.32 -Established criteria by Sousa et al.⁵⁴54 Sousa MH, Cecatti JG, Hardy EE, Serruya SJ. Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveil-lance. Reprod Health. 2008; 5: 6.	- Global rate of SMM: 52.9/1,000 childbirths -Absolute number: 4,890 cases, 4,225 were identified by the main diagnosis, 424 by procedures, 216 by ICU admission and 25 by secondary diagnosis - Rate by age group: 43.5 for 10-19 years old, 51.6 for 20-34 years old and 88.6 for 35-49 years old - Rate by criteria: Pre-eclampsia (14.9) and eclampsia (5.1); severe hemorrhage (12.5); immune disorder (7.4); severe sepsis (5.5); heart disorder (2.7) and ICU admission (2.3)

[TFN1] PLTC= Potential life-threatening conditions; SMO= severe maternal outcome=MNM+MD; HA= hypertension; HELLP= hemolysis elevated liver enzymes low platelet; CI= confidence interval; MD= maternal death; SMM= severe maternal morbidity; MNM= maternal near miss; LB= live births; WHO= World Health Organization; OR= odds ratio; MMR= maternal mortality ratio; SMMR= severe maternal morbidity ratio; PR= prevalence ratio; RR= relative risk; SUS= Public Health System; ICU= intensive care unit

Brasil

Brasil

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

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