Causes of maternal death and late maternal mortality: from the H1N1 to COVID-19 pandemics, State of Rio de Janeiro, 2009 to 2021

Bellizzi, Ana Lucia de Melo; Kale, Pauline Lorena; Fonseca, Sandra Costa; Cascão, Angela Maria

doi:10.1590/1806-9304202520250118-en

home Sumário navigate_before Anterior Atual Seguinte navigate_next

home Sumário

ORIGINAL ARTICLES • Rev. Bras. Saude Mater. Infant. 25 • 2025 • https://doi.org/10.1590/1806-9304202520250118-en linkcopy

Causes of maternal death and late maternal mortality: from the H1N1 to COVID-19 pandemics, State of Rio de Janeiro, 2009 to 2021

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives: to analyze the causes of maternal death (MD) and maternal late death (LMD), emphasizing the H1N1 and COVID-19 pandemics.

Methods: ecological study using data from national mortality and live birth systems. Causes were described according to the WHO Maternal Causes Classification (ICD-MM). Maternal, late, and comprehensive mortality ratios were calculated per 100,000 live births with 95% confidence intervals (CI).

Results: during pandemics, comprehensive mortality was higher: 104.6 (95%CI=95.3;114.5) in 2009-2010 (H1N1), 143.9 (95%CI=132.2;156.2) in 2020-2021 (COVID-19). Between 2020 and 2021, the indicator rose 33.5%. Direct causes predominated except in 2020-2021. The leading direct causes were hypertensive disorders, other obstetric complications, abortion, and hemorrhage. During pandemics, mortality due to hypertensive disorders increased, and among indirect causes, respiratory diseases in 2009-2010 (14.5; 95%CI=11.3-18.5) and other viral infections, mainly coronavirus (55.6; 95%CI=48.5-63.4), in 2020-2021 were prominent.

Conclusion: the comprehensive indicator more accurately quantifies the risk of death. Assigning specific causes to late maternal deaths and applying the ICD-MM classification can guide targeted prevention strategies.

key words
Maternal mortality; Cause of death; Influenza A virus; H1N1 subtype; COVID-19; Hypertension

Year/ period	Live Births (n)	Maternal Mortality			Late maternal mortality			Comprehensive maternal mortality
Year/ period	Live Births (n)	deaths (n)	%	MMR (IC95%)	deaths (n)	%	LMMR (95%CI)	deaths (n)	CMMR (95%CI)
2009	217280	224	92.6	103.1 (90.2;117.3)	18	7.4	8.3 (5.1;12.8)	242	111.4 (98.0; 126.1)
2010	215916	189	89.6	87.5 (75.7;100.7)	22	10.4	10.2 (6.6;15.2)	211	97.8 (85.2; 111.6)
2009/10	433196	413	91.2	95.3 (86.5;104.9)	40	8.8	9.2 (6.7;124.5)	453	104.6 (95.3; 114.5)
2011	221277	164	83.2	74.1 (63.4;86.1)	33	16.8	14.9 (10.4;20.7)	197	89.0 (77.23;102.1)
2012	223422	186	87.7	83.3 (71.9;95.9)	26	12,3	11.6 (7.8;16.8)	212	94.9 (82.8;108.3)
2013	224745	193	87.3	85.9 (74.4;98.7)	28	12.7	12.5 (8.4;17.8)	221	98.3 (86.0;112.0)
2011/13	669444	543	86.2	81,1 (74,5;88,2)	87	13.8	13.0 (10.5;16.0)	630	94.1 (87.0;101.7)
2014	234281	175	86.7	74.7 (64.2;86.4)	27	13.4	11.5 (7.8;16.5)	202	86.2 (74.9; 98.8)
2015	237591	167	86.5	70.3 (60.2;81.6)	26	13.5	10.9 (7.3;15.8)	193	81.2 (70.4; 93.3)
2016	219711	156	84.3	71.0 (60.5;82.8)	29	15.7	13.2 (9.0;18.7)	185	84.2 (72.7; 97.0)
2014/16	691583	498	86.0	72.0 (65.9;78.6)	82	14.0	11.9 (9.5;14.6)	580	83.9 (77.3; 90.9)
2017	223415	173	84.4	77.4 (66.5;89.6)	32	15.6	14.3 (10.0;20.0)	205	91.8 (79.8;105.0)
2018	221045	136	78.2	61.5 (51.8;72.5)	38	21.8	17.2 (12.3;23.4)	174	78.7 (67.6;91.1)
2019	208677	149	84.2	71.4 (60.6;83.6)	28	15.8	13.4 (9.0;19.1)	177	84.8 (73.0; 98.0)
2017/19	653137	458	82.4	70.1 (63.9;76.8)	98	17.6	15.0 (12.2;18.2)	556	85.1 (78.3; 92.4)
2020	199550	187	81.7	93.7 (80,9;107.9)	42	18.3	21.0 (15.4;28.2)	229	114.8 (100.6; 130.4)
2021	188989	288	87.3	152.4 (135.5;170.8)	42	12.7	22.2 (16.2;29.8)	330	174.6 (156.5; 194.2)
2020/21	388539	475	85.0	122.3 (111.6;133.6)	84	15.0	21.6 (17.4;26.6)	559	143.9 (132.2; 156.2)

Direct Causes	2009/2010		2011/2019		2020/2021		CMMR Ratio
Direct Causes	CMMR	95%CI	CMMR	95%CI	CMMR	95%CI	Aa	Bb
1- Pregnancy ending in abortion	11.1	8.3;14.6	8.9	4.2;4.8	7.5	5.1;10.6	1.2	0.8
Ectopic pregnancy (O00)	2.5	1.3;4.4	2.4	1.8;3.2	1.5	0.6;3.2	1.0	0.6
- Tubal Pregnancy - O00.1	2.5	1.3;4.4	2.3	1.7;3.1	1.3	0.5;2.9	1.1	0.6
2- Hypertensive disorders	13.4	10.3;17.2	11.4	10.0;13.0	17.5	13.7;22.1	1.2	1.5
Gestational hypertension with proteinuria (O14)	5.1	3.3;7.6	4.7	3.8;5.7	9.0	6.4;12.4	1.1	1.9
- Severe pre-eclampsia - O14.1	1.6	0.7;3.2	2.8	2.1;3.6	4.9	3.0;7.5	0.6	1.8
Eclampsia (O15)	4.4	2.7;6.7	4.3	3.4;5.3	6.2	4.0;9.1	1.0	1.4
- Unspecified eclampsia - O15.9	3.2	1.8;5.3	2.0	1.4;2.7	2.6	1.3;4.6	1.6	1.3
Maternal hypertension NE (O16)	2.8	1.5;4.7	1.1	0.7;1.9	0.5	0.1;1.7	2.4	0.5
3- Obstetric hemorrhages	5.8	3.8;8.4	7.5	6.4;8.8	6.7	4.5;9.7	0.8	0.9
Postpartum hemorrhage (O72)	2.8	1.5;4.7	3.4	2.6;4.3	2.6	1.3;4.6	0.8	0.8
-Other immediate postpartum hemorrhages-O72.1	0.9	0.3;2.2	2.3	1.7;3.0	1.3	0.5;2.9	0.4	0.6
4- Pregnancy-related infections	7.2	4.9;10.0	6.2	5.1;7.3	3.3	1.9;5.6	1.2	0.5
Puerperal Infection (O85)	2.3	1.2;4.1	3.2	2.5;4.1	1.5	0.6;3.2	0.7	0.5
Other Puerperal Infection (O86)	1.8	0.9;3.5	1.4	0.9;2.0	1.3	0.5;2.9	1.3	0.9
5-Other obstetric complications	15.0	11.7;1.9	10.6	9.2;12.1	8.8	6.2;12.1	1.4	0.8
Abnormalities of uterine contraction (O62)	3.5	2.0;5.6	1.7	1.2;2.4	1.5	0.6;3.2	2.0	0.9
- Other forms of uterine inertia - O62.2	3.5	2.0;5.6	1.7	1.2;2.4	1.5	0.6;3.2	2.0	0.9
Obstetric origin embolism (O88)	3.5	2.0;5.6	3.9	3.0;4.8	3.1	1.7;5.2	0.9	0.8
- Obstetric embolism due to blood clot - O88.2	1.6	0.7;3.2	2.0	1.4;2.7	1.5	0.6;3.2	0.8	0.8
Postpartum complications (O90)	5.1	3.3;7.6	3.8	3.0;4.7	3.1	1.7;5.2	1.3	0.8
- Cardiomyopathy - O90.3	4.4	2.7;6.7	3.3	1.2;6.2	2.6	1.3;4.6	1.3	0.8
6 - Unanticipated complications	0.5	0.8;15.3	0.3	0.2;0.7	0.3	0.0;1.2	1.3	1.0
Total	52.9	46.3;60.1	45	23.6;61.6	44	37.8;51.0	1.2	1.0

Causes	2009/2010		2011 - 2019		2020/2021		CMMR Ratio
Causes	CMMR	95%CI	CMMR	95%CI	CMMR	95%CI	Aa	Bb
Indirect Causes	39.2	33.7;45.5	43.0	39.6;46.6	84.7	75.9;94.2	0.9	2.0
7 - Non-obstetric complications	39.2	33.7;45.5	43.0	39.6;46.6	84.7	75.9;94.2	0.9	2.0
1 Maternal infectious and parasitic diseases complicating pregnancy. childbirth and the puerperium (O98)
- Tuberculosis complicating pregnancy/childbirth/puerperium - O98.0	2.3	1.2;4.1	1.1	0.7;1.6	1.0	0.3;2.5	2.1	0.9
- Viral hepatitis complicating pregnancy/childbirth/puerperium - O98.4	4.6	0.8;15.3	0.0	0.0;0.2	0.3	0.0;1.3	93.0	5.2
- Other viral diseases - O98.5	4.6	0.8;15.3	0.3	0.2;0.7	55.6	48.5;63.4	13.3	160.0
- HIV disease complicating pregnancy/childbirth/puerperium - O98.7	3.2	1.8;5.3	3.6	2.7;4.7	1.8	0.8;3.6	0.9	0.5
- Other maternal infectious diseases - O98.8	9.2	2.9;22.3	2.1	1.5;2.8	8.8	6.2;12.1	4.4	4.2
2 Other maternal diseases complicating pregnancy. childbirth and the puerperium (O99)
- Diseases of the circulatory system - O99.4	6.9	4.8;9.8	6.5	5.5;7.7	6.4	4.2;9.4	1.1	1.0
- Diseases of the respiratory system - O99.5	14.5	11.3;18.5	3.8	3.0;4.7	2.6	1.3;4.6	3.8	0.7
- Other diseases and nonspecific conditions - O99.8	3.7	1.7;5.0	5.1	4.1;6.1	3.3	1.1;4.2	0.7	0.7

Unspecified causes (O95)	3.9	2.4;6.2	5.5	4.6;6.6	4.1	2.4;6.6	0.7	0.7

vertical_align_top show_chart

more_horiz close
- image
- translate
- link
- article
- vertical_align_top
- file_download
- show_chart
- image
- translate
- link
- article

location_on

Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br

rss_feed Acompanhe os números deste periódico no seu leitor de RSS

[1] 95%CI= Confidence Interval of 95%;

[TFN1] ^a
CMMR A (ratio 2009-2010/2011-2019);

[TFN2] ^b
CMMR B (ratio 2020-2010/2021-2019).