Skip to main content

Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study



To assess the association between maternal potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD) with perinatal outcomes.


Cross-sectional study in 27 Brazilian referral centers from July, 2009 to June, 2010. All women presenting any criteria for PLTC and MNM, or MD, were included. Sociodemographic and obstetric characteristics were evaluated in each group of maternal outcomes. Childbirth and maternal morbidity data were related to perinatal adverse outcomes (5th min Apgar score < 7, fetal death, neonatal death, or any of these). The Chi-squared test evaluated the differences between groups. Multiple regression analysis adjusted for the clustering design effect identified the independently associated maternal factors with the adverse perinatal outcomes (prevalence ratios; 95% confidence interval).


Among 8271 cases of severe maternal morbidity, there were 714 cases of adverse perinatal outcomes. Advanced maternal age, low level of schooling, multiparity, lack of prenatal care, delays in care, preterm birth, and adverse perinatal outcomes were more common among MNM and MD. Both MNM and MD were associated with Apgar score (2.39; 1.68–3.39); maternal hemorrhage was the most prevalent characteristic associated with fetal death (2.9, 95% CI 1.81–4.66) and any adverse perinatal outcome (2.16; 1.59–2.94); while clinical/surgical conditions were more related to neonatal death (1.56; 1.08–2.25).


We confirmed the association between MNM and MD with adverse perinatal outcomes. Maternal and perinatal issues should not be dissociated. Policies aiming maternal care should include social and economic development, and improvements in accessibility to specialized care. These, in turn, will definitively impact on childhood mortality rates.

This is a preview of subscription content, access via your institution.

Fig. 1



Live births


Confidence interval


Low- and middle-income countries


Maternal death


Millennium development goals


Maternal near miss


Potentially life-threatening condition


Prevalence ratio


Severe maternal morbidity


Severe maternal outcomes


World Health Organization


  1. World Health Organization (2013) The world health report 2013: research for universal health coverage. Accessed 8 Dec 2018

  2. United Nations (2015) The millennium development goals report 2015: time for global action: for people and planet. Accessed 8 Dec 2018

  3. Lawn JE, Kinney MV, Black RE et al (2012) Newborn survival: a multi-country analysis of a decade of change. Health Policy Plan 27(Suppl 3):6–28.

    Article  Google Scholar 

  4. Guanais FC (2015) The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998–2010. Am J Public Health 105(Suppl):S5939–S58592.

    Article  Google Scholar 

  5. Duarte CMR (2007) Health policy effects on infant mortality trends in Brazil: a literature review from the last decade. Cad Saude Publica 23:1511–1528

    Article  PubMed  Google Scholar 

  6. Victora CG, Aquino EML, do Carmo Leal M et al (2011) Maternal and child health in Brazil: progress and challenges. Lancet 377:1863–1876.

    Article  PubMed  Google Scholar 

  7. Vogel JP, Souza JP, Mori R et al (2014) Maternal complications and perinatal mortality: findings of the World Health Organization multicountry survey on maternal and newborn health. BJOG 121(Suppl):76–88.

    Article  PubMed  Google Scholar 

  8. Nakimuli A, Mbalinda SN, Nabirye RC et al (2015) Still births, neonatal deaths and neonatal near miss cases attributable to severe obstetric complications: a prospective cohort study in two referral hospitals in Uganda. BMC Pediatr 15:1–8.

    Article  Google Scholar 

  9. Koné S, Hürlimann E, Baikoro N et al (2018) Pregnancy-related morbidity and risk factors for fatal foetal outcomes in the Taabo health and demographic surveillance system, Côte d’ Ivoire. BMC Pregnancy Childbirth.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cecatti JG, Souza JP, Parpinelli MA et al (2009) Brazilian network for the surveillance of maternal potentially life threatening morbidity and maternal near-miss and a multidimensional evaluation of their long term consequences. Reprod Health 6:15.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Haddad SM, Cecatti JG, Parpinelli MA et al (2011) From planning to practice: building the national network for the surveillance of severe maternal morbidity. BMC Public Health 11:283.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Cecatti JG, Costa ML, Haddad SM et al (2016) Network for surveillance of severe maternal morbidity: a powerful national collaboration generating data on maternal health outcomes and care. BJOG 123:946–953.

    Article  CAS  PubMed  Google Scholar 

  13. von Elm E, Altman DG, Egger M et al (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61:344–349.

    Article  Google Scholar 

  14. Say L, Souza JP, Pattinson RC (2009) Maternal near miss-towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 23:287–296.

    Article  PubMed  Google Scholar 

  15. Santana DS, Cecatti JG, Haddad SM et al (2017) Severe maternal morbidity and perinatal outcomes of multiple pregnancy in the Brazilian Network for the Surveillance of Severe Maternal Morbidity. Int J Gynecol Obstet 139:230–238.

    Article  Google Scholar 

  16. Souza JP, Cecatti JG, Parpinelli MA et al (2007) Appropriate criteria for identification of near-miss maternal morbidity in tertiary care facilities: a cross sectional study. BMC Pregnancy Childbirth 7:20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Hughes MM, Black RE, Katz J (2017) 2500-g low birth weight cutoff: history and implications for future research and policy. Matern Child Health J 21:283–289.

    Article  PubMed  Google Scholar 

  18. Pacagnella RC, Cecatti JG, Parpinelli MA et al (2014) Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth 14:159.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Anggondowati T, El-Mohandes AAE, Qomariyah SN et al (2017) Maternal characteristics and obstetrical complications impact neonatal outcomes in Indonesia: a prospective study. BMC Pregnancy Childbirth 17:1–12.

    Article  Google Scholar 

  20. Ganchimeg T, Ota E, Morisaki N et al (2014) Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG 121(Suppl):40–48.

    Article  PubMed  Google Scholar 

  21. World Health Organization (2014) Maternal mortality. Fact sheet no. 348. Accessed 8 Dec 2018

  22. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS et al (2014) Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384:980–1004.

    Article  PubMed  PubMed Central  Google Scholar 

  23. WHO, UNICEF, UNFPA WBG and the UNPD (2015) Trends in maternal mortality: 1990 to 2015. Accessed 8 Dec 2018

  24. Souza JP, Tuncalp O, Vogel JP et al (2014) Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 121(Suppl):1–4.

    Article  PubMed  Google Scholar 

  25. Domingues RMSM, Dias MAB, Schilithz AOC et al (2016) Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011–2012. Reprod Health 13(Suppl 3):115.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Oladapo OT, Adetoro OO, Ekele BA et al (2016) When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country. BJOG 123:928–938.

    Article  CAS  PubMed  Google Scholar 

  27. De Mucio B, Abalos E, Cuesta C et al (2016) Maternal near miss and predictive ability of potentially life-threatening conditions at selected maternity hospitals in Latin America. Reprod Health 13:1–10.

    Article  Google Scholar 

  28. Serruya SJ, De Mucio B, Martinez G et al (2017) Exploring the concept of degrees of maternal morbidity as a tool for surveillance of maternal health in Latin American and Caribbean settings. Biomed Res Int 2017:8271042.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Victora CG, Barreto ML, do Carmo Leal M et al (2011) Health conditions and health-policy innovations in Brazil: the way forward. Lancet 377:2042–2053.

    Article  PubMed  Google Scholar 

  30. Souza JP, Betran AP, Dumont A et al (2016) A global reference for caesarean section rates (C-model): a multicountry cross-sectional study. BJOG 123:427–436.

    Article  CAS  PubMed  Google Scholar 

  31. Kale PL, de Mello-Jorge MHP, da Silva KS et al (2017) Neonatal near miss and mortality: factors associated with life-threatening conditions in newborns at six public maternity hospitals in Southeast Brazil. Cad Saude Publica 33:1–12.

    Article  Google Scholar 

  32. Madeiro AP, Rufino AC, Lacerda EZG et al (2015) Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piaui, Brazil. BMC Pregnancy Childbirth 15:210.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Allanson ER, Muller M, Pattinson RC (2015) Causes of perinatal mortality and associated maternal complications in a South African province: challenges in predicting poor outcomes. BMC Pregnancy Childbirth 15:37.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Soma-Pillay P, Pattinson RC, Langa-Mlambo L et al (2015) Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa: a population-based study. S Afr Med J 105:563–578

    Article  Google Scholar 

  35. Lazzerini M, Richardson S, Ciardelli V et al (2018) Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review. BMJ Open 8:e019787.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Webbe J, Brunton G, Ali S et al (2017) Developing, implementing and disseminating a core outcome set for neonatal medicine. BMJ Paediatr Open 1:e000048.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Souza JP, Widmer M, Gulmezoglu AM et al (2014) Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise. Reprod Health 11:61.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Yoshida S, Rudan I, Lawn JE et al (2014) Newborn health research priorities beyond 2015. Lancet 384:e27–e29.

    Article  PubMed  Google Scholar 

  39. Tuncalp O, Souza JP, Hindin MJ et al (2014) Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey. BJOG 121(Suppl):57–65.

    Article  PubMed  Google Scholar 

Download references


We would like to thank our sponsors, the National Research Council (CNPq), through the Department of Science and Technology of the Brazilian Ministry of Health (DECIT); Grant number 402702/2008-5. We are also grateful to all the researchers from the Brazilian Network for the Surveillance of Severe Maternal Morbidity Group: Rodolfo C. Pacagnella, Rodrigo S. Camargo, Daniely S. Santana, Vilma Zotareli, Lúcio T. Gurgel, Fernanda G. Surita, Joao L. Pinto e Silva, Eliana M. Amaral, Lale Say, Robert C. Pattinson, Marilza V. Rudge, Iracema M. Calderon, Maria V. Bahamondes, Simone P. Gonçalves, Olímpio B. Moraes Filho, Simone A. Carvalho, Francisco E. Feitosa, George N. Chaves, Ione R. Brum, Gloria C. Saint’Ynes, Carlos A. Menezes, Patricia N. Santos, Everardo M. Guanabara, Elson J. Almeida Jr., Joaquim L. Moreira, Maria R. Sousa, Frederico A. Peret, Liv B. Paula, Luiza E. Schmaltz, Cleire Pessoni, Leila Katz, Adriana Bione, Antonio C. Barbosa Lima, Edilberto A. Rocha Filho, Melania M. Amorim, Ivelyne Radaci, Marilia G. Martins, Frederico Barroso, Fernando C. Oliveira Jr., Denis J. Nascimento, Cláudio S. Paiva, Moises D. Lima, Djacyr M. Freire, Roger D. Rohloff, Simone M. Rodrigues, Sergio M. Costa, Lucia C. Pfitscher, Adriana G. Luz, Daniela Guimaraes, Gustavo Lobato, Marcos Nakamura-Pereira, Eduardo Cordioli, Alessandra Peterossi, Cynthia D. Perez, Jose C. Peraçoli, Roberto A. Costa, Nelson L. Maia Filho, Jacinta P. Matias, Silvana M. Quintana, Elaine C. Moises, Fátima A. Lotufo, Luiz E. Carvalho, Carla B. Andreucci, Elvira A. Zanette, Márcia M. Aquino, Maria H. Ohnuma, Rosiane Mattar, and Felipe F. Campanharo.

Author information

Authors and Affiliations




DMZ has helped with project development and drafted the first manuscript. MAP has supervised the project development and edited the manuscript. SMH has designed the research proposal and managed the on-line data. MLC has supervised the project development and edited the manuscript. MHS has calculated the sample size and performed the statistical analysis. DFBL has collected data and edited the final version of the manuscript. JGC has designed the study proposal, supervised all the research procedures, and edited the final version of this manuscript.

Corresponding author

Correspondence to Jose G. Cecatti.

Ethics declarations

Conflict of interest

This study was funded by CNPq/DECIT (The National Research Council and the Department of Science and Technology of the Brazilian Ministry of Health), Grant number 402702/2008-5. This manuscript is solely authors’ responsibility and does not necessarily represent the official views of CNPq. CNPq did not influence on the decision to submit this manuscript or on its content. The authors declare that they have no conflict of interest.

Ethical statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent was waived. The research protocol was approved by the Institutional Review Board of University of Campinas on March 5th, 2009 (number 097/2009).

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zanardi, D.M., Parpinelli, M.A., Haddad, S.M. et al. Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study. Arch Gynecol Obstet 299, 645–654 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: