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.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Low- and middle-income countries
Millennium development goals
Maternal near miss
Potentially life-threatening condition
Severe maternal morbidity
Severe maternal outcomes
World Health Organization
World Health Organization (2013) The world health report 2013: research for universal health coverage. https://www.who.int/whr/2013/report/en/. Accessed 8 Dec 2018
United Nations (2015) The millennium development goals report 2015: time for global action: for people and planet. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20Summary%20web_english.pdf. Accessed 8 Dec 2018
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. https://doi.org/10.1093/heapol/czs053
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. https://doi.org/10.2105/ajph.2013.301452r
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
Victora CG, Aquino EML, do Carmo Leal M et al (2011) Maternal and child health in Brazil: progress and challenges. Lancet 377:1863–1876. https://doi.org/10.1016/S0140-6736(11)60138-4
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. https://doi.org/10.1111/1471-0528.12633
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. https://doi.org/10.1186/s12887-015-0362-3
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. https://doi.org/10.1186/s12884-018-1858-2
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. https://doi.org/10.1186/1742-4755-6-15
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. https://doi.org/10.1186/1471-2458-11-283
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. https://doi.org/10.1111/1471-0528.13614
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. https://doi.org/10.1016/j.jclinepi.2007.11.008
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. https://doi.org/10.1016/j.bpobgyn.2009.01.007
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. https://doi.org/10.1002/ijgo.12287
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. https://doi.org/10.1186/1471-2393-7-20
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. https://doi.org/10.1007/s10995-016-2131-9
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. https://doi.org/10.1186/1471-2393-14-159
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. https://doi.org/10.1186/s12884-017-1280-1
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. https://doi.org/10.1111/1471-0528.12630
World Health Organization (2014) Maternal mortality. Fact sheet no. 348. https://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality. Accessed 8 Dec 2018
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. https://doi.org/10.1016/S0140-6736(14)60696-6
WHO, UNICEF, UNFPA WBG and the UNPD (2015) Trends in maternal mortality: 1990 to 2015. https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/. Accessed 8 Dec 2018
Souza JP, Tuncalp O, Vogel JP et al (2014) Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 121(Suppl):1–4. https://doi.org/10.1111/1471-0528.12735
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. https://doi.org/10.1186/s12978-016-0232-y
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. https://doi.org/10.1111/1471-0528.13450
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. https://doi.org/10.1186/s12978-016-0250-9
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. https://doi.org/10.1155/2017/8271042
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. https://doi.org/10.1016/S0140-6736(11)60055-X
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. https://doi.org/10.1111/1471-0528.13509
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. https://doi.org/10.1590/0102-311x00179115
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. https://doi.org/10.1186/s12884-015-0648-3
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. https://doi.org/10.1186/s12884-015-0472-9
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
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. https://doi.org/10.1136/bmjopen-2017-019787
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. https://doi.org/10.1136/bmjpo-2017-000048
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. https://doi.org/10.1186/1742-4755-11-61
Yoshida S, Rudan I, Lawn JE et al (2014) Newborn health research priorities beyond 2015. Lancet 384:e27–e29. https://doi.org/10.1016/S0140-6736(14)60263-4
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. https://doi.org/10.1111/1471-0528.12634
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.
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.
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).
About this article
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). https://doi.org/10.1007/s00404-018-5004-1