Maternal deaths at a public maternity Hospital in Fortaleza: an epidemiological study

Abstracts

The objectives of this study were to analyze the maternal deaths, which occurred in a public maternity hospital in Fortaleza, Ceara State, Brazil and identify associations between time of death and the cases. An analysis was performed on the medical records, death certificates and notification forms regarding 96 maternal deaths that occurred between 2000 and 2008. The most prevalent delivery type was cesarean section (45, 46.8%) and the most prevalent causes of death were: hypertensive syndrome (27, 28.1%), infection (17, 17.7%) and hemorrhage (16, 16.7%). There was a statistically significant association between: cesarean section, hypertension syndrome and infection (x²=14.40, p=0.00; x²=4.02, p=0.04); deaths in the postpartum period and hypertensive syndrome (x²=6.13, p=0.01) and infection (x²=7.65, p=0.00). The characterization of these deaths helps in the recognition of groups at risk, and in developing preventive measures.

Maternal mortality; Women's health; Maternal-child nursing

O objetivo do estudo foi analisar os óbitos maternos ocorridos em uma Maternidade Pública de Fortaleza-CE e identificar a existência de associações entre o momento do óbito e as causas do óbito. Foram revisados prontuários, declarações de óbito e fichas de notificação referentes aos 96 óbitos maternos ocorridos entre 2000 e 2008. O tipo de parto mais prevalente foi o cesáreo (45;46,8%) e as causas de óbitos mais evidenciadas foram: síndrome hipertensiva (27;28,1%); infecção (17;17,7%); e hemorragia (16;16,7%). Houve associação estatística significante entre: cesariana e as causas de óbito síndrome hipertensiva e infecção (x²:14,40, p:0,00; x²:4,02, p:0,04); mortes ocorridas no puerpério e síndrome hipertensiva (x²:6,13, p:0,01) e infecção (x²:7,65, p:0,00). A caracterização desses óbitos auxilia no reconhecimento dos grupos de risco e na elaboração de medidas preventivas.

Mortalidade materna; Saúde da mulher; Enfermagem materno-infantil

El objetivo del estudio fue analizar los fallecimientos maternos ocurridos en una Maternidad Pública de Fortaleza, Cerá, Brasil e identificar la existencia de asociaciones entre momento del fallecimiento y causas del mismo. Fueron revisadas historias clínicas y fichas de notificación referentes a los 96 fallecimientos maternos ocurridos entre 2000 y 2008. El tipo de parto de mayor prevalencia fue la cesárea (45; 46,8%) y las causas de muerte más frecuentes fueron: síndrome hipertensivo (27; 28,1%), infección (17; 17,7%) y hemorragia (16; 17,7%). Existió asociación estadística significativa entre: cesárea y las causas de fallecimiento síndrome hipertensivo e infección (x²:14,40, p:0,00; x²:4,02, p:0,04); muertes ocurridas durante puerperio y síndrome hipertensivo (x²:6,13, p:0,01) e infección (x²:7,65, p:0,00). La caracterización de tales muertes ayuda a reconocer los grupos de riesgo y a elaborar medidas de prevención.

Mortalidad materna; Salud de la mujer; Enfermería maternoinfantil

ARTIGO ORIGINAL

Maternal deaths at a public maternity hospital in Fortaleza: an epidemiological study

Fallecimientos maternos en una Maternidad Pública de Fortaleza: un estudio epidemiológico

Marta Maria Soares Herculano^I; Ludmila Souza Veloso^II; Liana Mara Rocha Teles^III; Mônica Oliveira Batista Oriá^IV; Paulo César de Almeida^V; Ana Kelve de Castro Damasceno^VI

^IRN. Master student of the Graduate Program in Nursing, Universidade Federal do Ceará. Member of the Nursing Research Project on Maternal Health. Fortaleza, CE, Brazil. [e-mail]

^IIRN. Member of the Nursing Research Project on Maternal Health, Universidade Federal do Ceará. Fortaleza, CE, Brazil. [e-mail]

^IIIRN. Master student of the Graduate Program in Nursing, Universidade Federal do Ceará. CAPES Fellow. Member of the Nursing Research Project on Maternal Health. Fortaleza, CE, Brazil. [e-mail]

^IVRN. Ph.D. in Nursing. Post-Doctor, University of Virginia. Adjunct Professor of the Nursing Department, Universidade Federal do Ceará. Fortaleza, CE, Brazil. [e-mail]

^VStatistician. Ph.D. in Public Health. Adjunct Professor, Health Sciences Center, Universidade Estadual do Ceará. Fortaleza, CE, Brazil. [e-mail]

^VIRN. Ph.D. in Nursing. Adjunct Professor of the Nursing Department, Universidade Federal do Ceará. Coordinator of the Nursing Research Project on Maternal Health. Fortaleza, CE, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

The objectives of this study were to analyze the maternal deaths, which occurred in a public maternity hospital in Fortaleza-CE and identify associations between time of death and the cases. An analysis was performed on the medical records, death certificates and notification forms regarding 96 maternal deaths that occurred between 2000 and 2008. The most prevalent delivery type was cesarean section (45, 46.8%) and the most prevalent causes of death were: hypertensive syndrome (27, 28.1%), infection (17, 17.7%) and hemorrhage (16, 16.7%). There was a statistically significant association between: cesarean section, hypertension syndrome and infection (x²=14.40, p=0.00; x²=4.02, p=0.04); deaths in the postpartum period and hypertensive syndrome (x²=6.13, p=0.01) and infection (x²=7.65, p=0.00). The characterization of these deaths helps in the recognition of groups at risk, and in developing preventive measures.

Descriptors: Maternal mortality; Women's health; Maternal-child nursing

RESUMEN

El objetivo del estudio fue analizar los fallecimientos maternos ocurridos en una Maternidad Pública de Fortaleza-CE-Brasil e identificar la existencia de asociaciones entre momento del fallecimiento y causas del mismo. Fueron revisadas historias clínicas y fichas de notificación referentes a los 96 fallecimientos maternos ocurridos entre 2000 y 2008. El tipo de parto de mayor prevalencia fue la cesárea (45; 46,8%) y las causas de muerte más frecuentes fueron: síndrome hipertensivo (27; 28,1%), infección (17; 17,7%) y hemorragia (16; 17,7%). Existió asociación estadística significativa entre: cesárea y las causas de fallecimiento síndrome hipertensivo e infección (x²:14,40, p:0,00; x²:4,02, p:0,04); muertes ocurridas durante puerperio y síndrome hipertensivo (x²:6,13, p:0,01) e infección (x²:7,65, p:0,00). La caracterización de tales muertes ayuda a reconocer los grupos de riesgo y a elaborar medidas de prevención.

Descriptores: Mortalidad materna; Salud de la mujer; Enfermería maternoinfantil

INTRODUCTION

Maternal death is the death of a woman while pregnant, during labor or within 42 days of pregnancy outcome, irrespective of the duration or site of the pregnancy. When death occurs after 42 days but within one year after the pregnancy outcome, it is denominated as a late maternal death. In addition, death caused by spontaneous miscarriages and unsafe abortions⁽¹⁾ are also considered to be maternal deaths.

The World Health Organization (WHO) considers a Maternal Mortality Ratio (MMR) lower than 20 deaths per 100,000 live births as low, between 50 and 149 as high, and above 150⁽²⁾ as very high. In Brazil, MMR varies around 70 deaths per 100,000 live births. In 1990 in Brazil the MMR was 128 deaths per 100,000 live births and in 2008 it was registered as 74⁽³⁾.

The MMR of a country is an excellent indicator of its social reality, since it is inversely related to the human development rate. It reflects the quality of medical care delivery, gender iniquity and the political determination of public health promotion. The lower the development rate in the region, the higher is the prevalence of high blood pressure, hemorrhage and infectious syndromes in the maternal obituary. As the region develops, these causes of death tend to decrease progressively and are substituted for other causes that are more difficult⁽²⁾ to solve.

Main causes that trigger maternal death may be classified as: direct obstetric causes (resulting from complications exclusively related to the pregnancy period), indirect obstetric causes (resulting from pre-existing conditions aggravated by pregnancy) and non-obstetric or unrelated to obstetric causes (resulting from other accidental or incidental causes occurring during the pregnancy period, but not related to it)⁽⁴⁾.

In Brazil, despite the progress made in maternity care at clinics (increase in prenatal care coverage and access to laboratory exams) and hospitals (encouraging natural childbirth, the adoption of clinical protocols for handling pathologies and intercurrences), the actions developed are less effective than expected in decreasing maternal mortality. The main causes of maternal death have been hemorrhage and hypertension, both avoidable with quality prenatal and child delivery⁽⁵⁾ care.

Nursing interventions aimed at the obstetric area are based on, among other aspects, preventing complications through quality care delivery. Therefore, verifying which women die, for what reason and in which period (pregnancy or puerperal period) becomes relevant. Studies have analyzed this subject in other northeastern states^(6-7)_; however, each site has its own specificities, resulting in the need to perform this study to learn about maternal mortality in the reality of the State of Ceará.

The initial hypothesis of this study is to determine the relationship between the type of labor and the puerperal-pregnancy cycle and cause of death by hypertensive syndrome, infection and hemorrhage.

The objectives of this study were to analyze maternal deaths, which occurred in a public maternity hospital in Fortaleza-CE and identify associations between the moment of death and its cause.

METHOD

Cross-sectional study with a quantitative approach, performed between March and November of 2009. The study population was composed of women who died due to maternal causes between 2000 and 2008 in a public maternity hospital in Fortaleza, a referring institution for obstetrics in the State of Ceará.

The institution was chosen because it is the only one in the State of Ceará that contains a Maternal Intensive Care Unit (ICU). Such a feature has been presented as important since women with severe maternal morbidity are generally transferred to this institution. In addition, the Maternity ICU has an operating Maternal Mortality Committee, which helps in maintaining more accurate and detailed information in the investigation files and in the classification of maternal death.

In order to achieve the objectives proposed by this study, the following methodology pathway was performed: first, the Epidemic Control and Preparedness Unit (ECPU) was researched in order to access death certificates and maternal death investigation files, from which the women who died due to maternal cause were selected. After that, having compiled a list of 96 women who died due to maternal death between 2000 and 2008, the Medical Record and Statistics Service (MRSS) of the institution was surveyed for the medical records of these women.

Hence, the available information in the medical records of these women who died due to maternal causes were used (number of pregnancies, deliveries and abortions, time of death and type of childbirth), including death certificates (identification and cause of death) and the investigation instrument used by the Maternal Mortality Committee (prenatal care and death classification – direct or indirect obstetric causes).

Data were analyzed using the Statistical Package for Social Sciences for Personal Computer (SPSS-PC) software, version 17.0. The statistical associations between variables were calculated using the Pearson Chi-Square (x²) statistics tests and the Fisher Exact Test. Correlations settings were evaluated through the Spearman test. Associations were considered significant when p<0.05. Results were presented in tables and discussed according to pertinent literature.

This study was approved by the Research Ethics Committee of the institution under protocol No 85/08. All ethical recommendations and requirements previewed in Resolution No 196/96⁽⁸⁾ were respected.

RESULTS

The institution presented 96 deaths due to maternal causes in the period between 2000 and 2008, varying between 4 (4.1%) in 2001 and 16 (16.5%) in 2004. As for the women's age bracket, 19 (19.8%) were between 10 and 19 years, 57 (59.4%) were between 20 and 34 years, and 20 (20.8%) were between 35 and 49 years.

Variables such as marital status, race/color and education were discarded from the study since they presented excessive and extraneous information.

We observed that 37 (38.5%) of the women who died received prenatal care. Of these women, 19 (51.3%) had had more than six appointments, followed by 10 (27%) women with less than three appointments and 6 (16.2%) with between three and five appointments. Lack of information regarding prenatal care was observed in 58 (60.4%) cases; in other words, more than half of the subjects. Regarding the number of prenatal appointments, 60 (62.5%) cases had no record of them, making statistical associations between maternal death and prenatal appointments unfeasible.

Regarding the women's origin, 44 ( 46%) came from the metropolitan region, represented here by Caucaia, Aquiraz, Pacatuba, Maranguape, Maracanaú, Eusébio, Guaiúba, Itaitinga, Chorozinho, Pacajus, Horizonte and São Gonçalo do Amarante, as well as other municipalities of the interior of the State. Such data presents the character of the reference unit presented by the institution.

In the Maternity unit in this study, there are two ways in which women can be admitted for an obstetric emergency: directly admitted from their home and transferred from other hospitals. When investigating the admittance status of the subjects, we observed that 24 (25.0%) were from the city of Fortaleza, 4 (4.2%) from the interior of the State, 26 (27.0%) were transferred from other hospitals in Fortaleza and 40 (41.8%) were transferred from hospitals in the neighboring cities.

Childbirth types, time and cause of death are presented in Table 1.

A statistically significant association between performing a C-section and causes of death such as gestational hypertension syndrome and infection were observed (x²:14.406, p:0.000; x²:4.021, p:0.045).

The highest maternal deaths percentages between 2000 and 2008 were related to gestational hypertensive syndromes, represented by pre-eclampsia, eclampsia and HELLP syndrome. The variable others, although with a rate of 29.2% is not presented as the majority, represent non-obstetric maternal deaths.

No statistical significances between women's age and gestational hypertensive syndrome were found (r_s=-0.060; p=0.560). However, these two variables tend to present an inverse relation: the lower the woman's age, the higher the chance for a hypertensive syndrome as cause of death. A direct correlation between age and infections as the cause of death (r_s= 0.296; p=0.03) and between age and abortion (r_s= 0.217; p=0.03) were observed.

Puerperium was the period that held most deaths. A statistical association between deaths in this period and hypertensive syndrome and infection was observed.

We identified that 62% of deaths were related to direct obstetric causes, 18% to indirect obstetric causes and 20% had insufficient information. Death certificates with no information were mostly declarations in which the medical professional did not register the cause of death. These declarations were forwarded to the maternal mortality committee of the institution in order to complete an investigation and to be coded. Information decided within the committee is registered neither in the medical file nor the death certificate. Information is coded and directly entered in the Mortality Information System (SIM in Brazilian acronyms). Hence, even in cases when the cause of death was found, the information could not be accessed in the data sources surveyed.

DISCUSSION

Regarding the age of women who died, we observed that they were mostly between 20 and 34 years old. A study performed in another northeastern state also observed that most maternal deaths occurred within this age bracket (65; 59.7%)⁽⁶⁾.

The age bracket between 20 and 34 concentrates the most fertile⁽⁹⁾ period in childbirth years; therefore, pregnancy within this age bracket offers lower risks to women^(10-11). Deaths occurring within this age bracket reflect the need to improve prenatal, childbirth and puerperium care and to promote the early discovery and appropriate handling of medium/high risk pregnancies.

We also reported in this study that deaths occurring in both reproductive age extremes, even though they represent a low percentage, could have been avoided if high reproductive risk pregnancies were avoided or (even better), planned using effective family planning initiatives, mitigating the maternal and unborn risks, as an important measure of health promotion⁽¹⁰⁾. Family planning allows for the pregnancy to occur at a good time in a woman's life; in other words, when the woman is biologically and psychologically prepared for the experience of the puerperal-pregnancy cycle, offering less risks of becoming ill or dying.

Regarding marital status, race and education we observed that most records (66, 72 and 77%, respectively) presented no information regarding these variables, therefore making it impossible to evaluate the profile of deaths according to these features. Two factors still make the actual maternal mortality level and trend monitoring in Brazil difficult: under-information and under-registration in declarations of cause of death⁽¹⁾. This fact hampers evaluating the problem, and consequently elaborating preventive and corrective measures for the situation.

Regarding prenatal care, a deficient record for this variable was also observed. This is a regrettable fact, since it hampers acknowledgement from appropriate health care levels and highlights major deficiencies in health care for pregnant women. Theoretically, quality and easily accessed prenatal care could identify risk factors for maternal morbidity and mortality, allowing for the appropriate interventions. Maternal mortality reflects a lack of quality in the care provided by health services, and also an unsatisfactory practice of public policies aimed at women's health⁽¹²⁾.

Maternal mortality magnitude is related to access and quality deficiencies in health actions and services and to precarious prevention and promotion of sexual and reproductive health measures. Non-continuous actions, lack of integration between care levels and between professionals, and the lack of connection between women and service and health teams correspond to the reduction of reproductive and sexual health care quality and, therefore, to maternal death⁽¹³⁾. Failure to have appropriate prenatal care may allow patients to evolve from simple morbidity during pregnancy to maternal death. Lacking to follow pre-natal care may permit patients to evolve from a simple morbidity during pregnancy to more severe situations, not blocking the course: healthy pregnancy – pathologic pregnancy.

Regarding pregnancy outcomes, high levels of C-sections were observed, probably due to the high number of high-risk pregnancies that this institution receives. These patients' conditions require urgent C-section, not allowing the development of favorable cervical conditions for a normal childbirth. A retrospective study of 144 maternal deaths in the Juiz de Fora Federal University maternity ward over a period of 75 years observed that when a C-section is inevitable, the risk associated with it is lower (relative risk = 0.6) than with normal childbirth labor⁽¹⁴⁾.

When maternal gestational hypertensive syndrome is verified, a C-section is advised. In case of stable maternal condition, childbirth is postponed until the 40^th week⁽¹⁵⁾. Believing that the majority of pregnant women sent to the maternity unit in this study presented complications of pregnancy, the association between C-section and hypertensive syndrome can be justified by the recommendation of a C-section for women presenting altered blood pressure levels or with signs/symptoms of maternal or unborn instability or risk.

The association between C-section and infection as cause of death can be correlated to complications of this surgical procedure. C-section, as with any other surgery, is associated with risks and benefits. Among the risks, postpartum infection is the most prevalent, a consequence of the local necrosis caused by the surgical trauma associated with the contamination of the abdominal cavity with amniotic fluid and a higher amount of blood loss⁽¹⁶⁾. Among the benefits, there is a reduction in maternal and the unborn risk due to pathologic alterations.

Hypertensive syndromes represent the main cause of death among the women in this study. Women's race and the medical treatment offered can be related to death by eclampsia. In a retrospective study cohort performed in the Sorocaba Hospital Compound it was verified that black and dark-skinned women presented a higher death risk (RR=9.10; IC95%=1.83-45.23; p=0.007), and that those treated with magnesium sulphate presented a lower death risk (RR=0.08; IC95%=0.02-0.35; p=0.001)⁽¹⁷⁾.

Although of unknown etiology, some factors are believed to favor hypertensive syndromes. Among them are: race (more common among black women), obesity, first pregnancy, multiple pregnancies and age (more common with age extremes)⁽¹⁸⁾, where the last can justify the negative relation between age and the occurrence of hypertensive syndrome observed in this present study.

The direct relationship between the women's age and infection can be justified by the higher occurrence of abortions in women of a higher age demonstrated in this study. One of the current concerns is the increase in mortality through abortion, especially illegal abortions. The lack of family planning and precarious socio-economic conditions justify this reality⁽¹¹⁾. Nursing care provided to women undergoing abortion must reach beyond the interpretation of signs and symptoms as something organic; the nursing professional must take a broader, less mechanistic and reductive care⁽¹⁹⁾. Comprehensive care and health education can contribute towards empowering women regarding reproductive planning, consequently reducing the number of willful abortions and maternal deaths.

This present study observed that most deaths occurred in puerperium. This fact infers that patients received the appropriate treatment, anticipating childbirth and receiving other pertinent clinical care; in this manner, death may occur due to a late decision in searching for health care and difficulties in accessing medical care.

Puerperium brings potential risks for maternal complications. In a study performed with 291 women admitted to the maternal ICU in Pernambuco under the near-miss criteria, 234 women (80.4%) were in the puerperium, and the main causes for admission were: hypertension (228; 78.4%), hemorrhage (74; 25.4%) and puerperal infection (22; 9,4%)⁽²⁰⁾.

There was an association between puerperium and hypertensive syndrome. The postpartum period brings great physical and pathologic alterations, including the self-transfusion effect occurring in the immediate puerperium after the placenta is expelled, when there is an abrupt return of more than 800ml of blood to the maternal bloodstream. These, and other adjustments experienced by the mother in this period, can enhance many complications of hypertensive syndromes⁽²¹⁾.

The association between puerperium and infection as the cause of death can be related to puerperal infections, featured by fever higher or equal to 38ºC, occurring in the first 24hrs after childbirth, followed (or not) by general symptoms such as headaches, chills, malaise, restlessness, anxiety, and tachycardia. Factors putting women at risk of puerperal infection include: premature rupture of amniotic membranes, C-section, urinary catheters, retention of placental fragments, among others⁽²²⁾. In developed countries, puerperal infections are responsible for 25% of maternal deaths⁽¹⁶⁾.

It is important to point out that a great variety of care is necessary for women during puerperium. It is common, following labor, to provide care and attention to the newborn infant; however, the women in puerperium also require close monitoring, ensuring the continuity and quality of care delivery. Monitoring blood pressure, signs and symptoms of infection, hypovolemic shock and hemorrhage are the minimum care that should be provided by the nursing team.

Maternal deaths classified as direct obstetric causes were predominant. These cases could, almost all of them, have been avoided by basic measures such as: quality prenatal care, health education for pregnant women and the appropriate obstetric care in hospital. Similar findings were observed in a research regarding the socio-demographic profile and the cause of maternal mortality in the period between 2004 and 2007 in a teaching hospital in Curitiba- PR. In this present study, deaths were classified as avoidable in 80.6% of the cases and they occurred due to direct causes in 45.16% cases⁽¹²⁾. Therefore, there is an equal reality regarding maternal mortality issues in different regions of Brazil.

CONCLUSION

A low quality in death investigation records was observed, preventing an actual and true knowledge of the social context in which the women who died were present. Health professionals must acknowledge the correct input of information into documents regarding maternal mortality.

Direct obstetric causes were predominant, and various clinical forms of gestational hypertensive syndrome were the main determining factors. The period of puerperium was the period in which death occurred most often. In addition, an association between the deaths occurred in this period, in which hypertensive syndrome and infection were identified. An association between C-section and death by hypertensive syndrome and infection was verified. Therefore, the need for continuous monitoring of women in the postpartum period, particularly those who underwent a C-section, checking for early signs and symptoms indicating these pathologies, is warranted.

Maternal mortality remains a present problem in our society, holding high rates and resulting from the inter-relation of many processes. Appropriate measures to combat maternal mortality must be identified and strived towards, acknowledging peculiarities of different groups and contexts.

The limitations of this present study were: the sample studied included subjects in an outsourced public service and not from the general population; and loss of information due to flaws in records and lack of using a partogram for collecting data.

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Correspondência:

Marta Maria Soares Herculano

Rua Ministro Joaquim Bastos, 471 - Apto 701 - Fátima

CEP 60415-040 – Fortaleza, CE, Brasil

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  19 Nov 2010
• Accepted
  06 Sept 2011