BackgroundThe vast majority of maternal deaths in low-and middle-income countries are preventable. Delay in obtaining access to appropriate health care is a fairly common problem which can be improved. The objective of this study was to explore the association between delay in providing obstetric health care and severe maternal morbidity/death.MethodsThis was a multicentre cross-sectional study, involving 27 referral obstetric facilities in all Brazilian regions between 2009 and 2010. All women admitted to the hospital with a pregnancy-related cause were screened, searching for potentially life-threatening conditions (PLTC), maternal death (MD) and maternal near-miss (MNM) cases, according to the WHO criteria. Data on delays were collected by medical chart review and interview with the medical staff. The prevalence of the three different types of delays was estimated according to the level of care and outcome of the complication. For factors associated with any delay, the PR and 95%CI controlled for cluster design were estimated.ResultsA total of 82,144 live births were screened, with 9,555 PLTC, MNM or MD cases prospectively identified. Overall, any type of delay was observed in 53.8% of cases; delay related to user factors was observed in 10.2%, 34.6% of delays were related to health service accessibility and 25.7% were related to quality of medical care. The occurrence of any delay was associated with increasing severity of maternal outcome: 52% in PLTC, 68.4% in MNM and 84.1% in MD.ConclusionsAlthough this was not a population-based study and the results could not be generalized, there was a very clear and significant association between frequency of delay and severity of outcome, suggesting that timely and proper management are related to survival.

BackgroundPreterm birth rate is increasing and is currently a worldwide concern. The purpose of this study was to estimate the prevalence of preterm birth in a sample of health facilities in Brazil and to identify the main risk factors associated with spontaneous preterm births.Methods and FindingsThis was a multicentre cross sectional study on preterm births in 20 referral obstetric hospitals with a case-control component to identify factors associated with spontaneous preterm birth. Surveillance was implemented at all centres to identify preterm births. For eligible consenting women, data were collected through a post-delivery questionnaire completed with information from all mother-newborn medical records until death or discharge or at a maximum of 60 days post-delivery, whichever came first. The risk of spontaneous preterm birth was estimated with OR and 95%CI for several predictors. A non-conditional logistic regression analysis was then performed to identify independently associated factors. The overall prevalence of preterm birth was 12.3%. Among them, 64.6% were spontaneous and 35.4% therapeutic. In the case-control component, 2,682 spontaneous preterm births were compared to a sample of 1,146 term births. Multivariate analyses identified the following as risk factors for spontaneous preterm birth among women with at least one previous birth: a previous preterm birth (ORadj = 3.19, 2.30–4.43), multiple pregnancy (ORadj = 29.06, 8.43–100.2), cervical insufficiency (ORadj = 2.93, 1.07–8.05), foetal malformation (ORadj = 2.63, 1.43–4.85), polyhydramnios (ORadj = 2.30, 1.17–4.54), vaginal bleeding (ORadj = 2.16, 1.50–3.11), and previous abortion (ORadj = 1.39, 1.08–1.78). High BMI (ORadj = 0.94, 0.91–0.97) and weight gain during gestation (ORadj = 0.92, 0.89–0.95) were found to be protective factors.ConclusionsThe preterm birth rate in these health facilities in Brazil is high and spontaneous preterm births account for two thirds of them. A better understanding of the factors associated with spontaneous preterm birth is of utmost importance for planning effective measures to reduce the burden of its increasing rates.

SAWAYA, ANA L, GERALD DALLAL, GISELA SOLYMOS, MARIAHDESOUSA, MARIAL-, SUSANB ROBERTSAND DIRCE M SIGULEM. Obesity andmalnutritionin a shantytown populationin the city of SIioPaulo,Brazil. Obes Res. 1995;3(supp12):107~-115~. To investigatethe prevalence of obesity and malnutrition inthe poor Brazilianpopulationweconducted asurveyon the socioeconomic and nutritional status of 535 families (comprising2 411 individuals)livinginshantytownsinthe cityofSIioPaulo. Therewas a30% prevalenceofmalnutrition in the children, with chronic malnutrition as the mostpredominantproblem. Theprevalenceofobesitywas 6.4% in boys and 8.7% in girls. Overweight and obesity associated with stunting was found in 5.8% of boys and 6.8% girls. Adolescents showed a higher prevalence of malnutrition when weight-for-age distribution was used (boys 46.4%, girls 40.2%), but a right deviation in the distributionwas observedwith anincreaseinobesity and adecreaseof malnutritionwasobsered (obesity was 21% ingirlsand8.8% inboys;malnutritionwas 15.5% inboys and 12.6% in girls) when the weight-for-height adjustmentwasmade. Stuntingwas themost predominanttype of malnutrition in both sexes. Obesity associated with stuntingwas morecommon than obesitywithout stunting, bothin younger children and adolescents. Adults had a higher prevalence of obesity than malnutrition according to both the Metropolitan Life Insurance tables (1.7% of undernutrition, 16.7% of overweight , and 14.1% of obesity) and Body Mass Index (8.5% of undernutrition, 21.9% of overweight, and 14.6% of obesity). There was an increase in the percentage of obese children when at least one adult in the family was obese and an increased percentage of malnourished children when undernour- ishedadultswerepresentinthefamily. Obesity amongthe adults of the family decreased the occurrence of malnutrition among the children. In 9% of families there was a coexistenceofobesity intheadults andmalnutritioninthe children. These results demonstrate a coexistence of malnutrition and obesity in poor urban Braziliancommunities.

BackgroundHypertensive disorders represent the major cause of maternal morbidity in middle income countries. The main objective of this study was to identify the prevalence and factors associated with severe maternal outcomes in women with severe hypertensive disorders.MethodsThis was a cross-sectional, multicenter study, including 6706 women with severe hypertensive disorder from 27 maternity hospitals in Brazil. A prospective surveillance of severe maternal morbidity with data collected from medical charts and entered into OpenClinica®, an online system, over a one-year period (2009 to 2010). Women with severe preeclampsia, severe hypertension, eclampsia and HELLP syndrome were included in the study. They were grouped according to outcome in near miss, maternal death and potentially life-threatening condition. Prevalence ratios and 95% confidence intervals adjusted for cluster effect for maternal and perinatal variables and delays in receiving obstetric care were calculated as risk estimates of maternal complications having a severe maternal outcome (near miss or death). Poisson multiple regression analysis was also performed.ResultsSevere hypertensive disorders were the main cause of severe maternal morbidity (6706/9555); the prevalence of near miss was 4.2 cases per 1000 live births, there were 8.3 cases of Near Miss to 1 Maternal Death and the mortality index was 10.7% (case fatality). Early onset of the disease and postpartum hemorrhage were independent variables associated with severe maternal outcomes, in addition to acute pulmonary edema, previous heart disease and delays in receiving secondary and tertiary care.ConclusionsIn women with severe hypertensive disorders, the current study identified situations independently associated with a severe maternal outcome, which could be modified by interventions in obstetric care and in the healthcare system. Furthermore, the study showed the feasibility of a hospital system for surveillance of severe maternal morbidity.

BackgroundTwin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth.MethodsSecondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI.ResultsThe occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy.ConclusionTwin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.