Assistance process to women with severe maternal morbidity: a mixed study

To describe the maternal and obstetric characteristics associated with severe maternal morbidity, and the factors of the assistance process involved in the severe outcomes according to nurses and doctors.

Method:

Sequential mixed study at the tertiary maternity in the city of Rio de Janeiro, based on care records and interviews with these professionals, from February to July 2019. Chi-square test, prevalence ratio and thematic content analysis were applied.

Results:

In 66 (100%) women with SMM, severe preeclampsia (77.3%) was more prevalent and there were 12 (18.2%) cases of near miss and one maternal death. Postpartum hemorrhage (PR = 3.21; 95% CI 1.22-8.41) and blood transfusions (PR = 3.60; 95% CI 1.81-7.16) contributed to severe outcomes. There are deficiencies in the health system, access to reproductive health and quality of care.

Conclusion:

Improvements in access to health and quality of the care process are imperative to reduce severe maternal outcomes.

Keywords:
Pregnancy complications; Morbidity; Quality of health care

Criteria	N (%)	Criteria	N (%)
World Health Organization⁵	N (%)	Mantel	N (%)
Clinical criteria		Emergency hysterectomy	4 (6.0)
Severe postpartum hemorrhage	12 (18.2)	Hypovolemia - replacement of ≥ 5 units	3 (4.5)
Severe preeclampsia	51 (77.3)	Pulmonary edema	-
Eclampsia	3 (4.5)	Admission to Intensive Care Unit	10 (15.1)
Sepsis/severe systemic infection	7 (10.6)		1 (1.5)
Uterine rupture	-	Coagulation dysfunction	3 (4.5)
Critical interventions		Brain dysfunction	2 (3.0)
Admission to ICU	10 (15.1)	Respiratory dysfunction	3 (4.5)
Blood transfusions	18 (27.2)	Liver dysfunction	1(1.5)
Uterine artery embolization	1 (1.5)
Hysterectomy	4 (6.0)
Other emergency surgical interventions in the abdominal cavity	11 (16.6)
Organic dysfunctions		Geller
Cardiovascular dysfunction	5 (7.5)	Organic failure	12 (18.2)
Respiratory dysfunction	3 (4.5)	Admission to the Intensive Care Unit	10 (15.1)
Kidney dysfunction	1 (1.5)	Blood transfusion of ≥ 3 units	10 (15.1)
Uterine dysfunction	4 (6.0)	Prolonged intubation (>12 h)	3 (4.5)
Hematological dysfunction	4 (6.0)	Surgical interventions	12 (18.2)
Liver dysfunction	1 (1.5)	Scoring
Neurological dysfunction	2 (3.0)	Below 8	54 (81.8)
Management		8-9	6 (9.0)
Intubation and ventilation ≥ 60 minutes	3 (4.5)	10-11	2 (3.0)
Cardiopulmonary resuscitation	5 (7.5)	12-13	3 (4.5)
Vasoactive drugs	5 (7.5)	14-15	1 (1.5)
Blood transfusion of ≥ 5 units	3 (4.5)
Hysterectomy	4 (6.0)
Dialysis	1(1.5)

Variables	Maternal Morbidity				Cramer /Phi	PR	CI 95%
	Severe (n=54)	Near Miss (n=12)	Total		Cramer /Phi
	n (%)	n (%)	n (%)	p	V/(
Severe complication grave
Postpartum hemorrhage	7 (10.6)	5 (7.6)	12 (18.2)	0.019	0.287	3.21	1.22 - 8.41
Severe preeclampsia	47 (71.2)	4 (6.1)	51 (77.3)	<0.001	0.494	0.38	0.17 - 0.85
Sepsis	3 (4.5)	4 (6.1)	7 (10.6)	0.005	0.348	6.00	1.54 - 23.77
Eclâmpsia	2 (3.0)	1 (1.5)	3 (4.5)	0.486	0.086	2.25	0.22 - 22.83
Other complications*	-	5 (7.6)	5 (7.6)	<0.001	0.607	0.58	0.36 - 0.94
Critical intervention
Admission to ICU	2 (4.5)	8 (12.1)	10 (15.2)	<0.001	0.677	18.00	4.36 - 74.29
Emergency abdominal surgery	2 (3.0)	5 (7.6)	7 (10.6)	<0.001	0.476	11.25	0.24 - 51.22
Blood transfusion	10 (15.2)	8 (12.1)	18 (27.3)	0.001	0.417	3.60	1.81 - 7.16
Uterine artery embolization	-	1 (1.5)	1 (1.5)	0.030	0.263	-	-

Theme	Subthemes	RU (%)
Care process factors associated with severe maternal morbidity
	Deficiencies in the health care system	28,3
	Low quality of primary and hospital care	28.3
	Lack of professional training	25.2
	Low maternal socioeconomic status	12.8
	Difficulty in accessing reproductive health	5.4

Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
E-mail: revista@enf.ufrgs.br

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[1] Corresponding author:
Jessica Paola Garcia Villalba E-mail: yeco0910@gmail.com