Morbidade materna grave: evolução temporal, principais causas e efeito da atenção primária à saúde sobre as hospitalizações por esses agravos no Brasil Salvador.

Abstract

Severe maternal morbidity (SMM) is a situation of obstetric severity with a potential risk of death in the pregnancy-puerperal cycle and an important indicator to monitor, assess the quality and improve maternal health care. This problem is potentially avoidable by a set of prenatal care actions (ACN), which represents a basic action in the scope of activities developed in Primary Health Care (PHC). This Thesis aimed to characterize SMM, describe its temporal trend, and evaluate the effect of the Family Health Strategy (FHS) considering ACN coverage on the evolution of SMM and its specific causes in Brazilian municipalities. The thesis was built in the format of three articles, the first being an essay that aimed to present and discuss the concepts and criteria used for the classification of maternal near miss or SMM in the world. The study evidenced the existence of polysemy of terms and definitions, as well as a lack of consensus in their definition, which contributes to the global burden and extent of the problem in the whole world not being fully known. Efforts to create SMM indicators to understand the global burden of disease in the pregnancy-puerperal cycle and to monitor and assess the quality of maternal health have demonstrated advances in the propositions of more sensitive and appropriate classifications for the different contexts in each country. However, several challenges remain, especially related to the different widely used classifications, making it necessary to standardize the criteria to compare different scenarios, at different periods, and assess the impact of interventions. Article 2 aimed to analyze the temporal trends of hospitalization rates for SMM and its main causes in Brazil and regions in the period 2000 to 2017 and used the segmented regression model to estimate the average annual percentage variation (Annual Percent Change – APC) in specific segments of a time series and the weighted average of the APC obtained in the segmented analysis (Average Annual Percent Change – AAPC). The results of this article showed an increase (AAPC=3.1; 95%CI: 2.3;3.9) in hospitalization rates for SMM in Brazil and most regions. The analysis of specific causes showed an increase in the rates of hospitalizations for eclampsia (AAPC=14.9%; 95%CI: 8.3; 21.9), admission to the ICU (AAPC=7.1%; 95%CI:3.7 ;10.6) and preeclampsia (AAPC:6.6; 95%CI:5.2;8.0); stability in the rates of hospitalizations for severe hemorrhage (AAPC: -0.4; 95%CI: -1.7;0.8); and reduction in the rates of hospitalizations for sepsis (AAPC=-2.7; 95%CI:-3.8; -1.6), with different behaviors between regions. The last article of the thesis evaluated the effects of expanding PHC and ACN coverage on hospitalizations for SMM and according to specific causes of hypertensive syndromes and sepsis, in Brazilian municipalities, using regression models with a negative binomial response and fixed effects. The results revealed that the consolidation of the PHC and ACN was associated with an increase in hospitalizations for SMM (RR=1.64; 95%CI: 1.60-1.67) and hypertensive syndromes (RR=1.70; 95%CI: 1.66-1.75) and reduction in hospitalizations for sepsis (RR=0.83; 95%CI: 0.80-0.87) in Brazilian municipalities. The effects of PHC and ACN seem to indicate failures in ACN, but the findings may reveal that hospitalizations may have occurred in the most severe spectrum and therefore were not avoidable and that referrals occurred promptly to the level of higher technological density, avoiding possible complications or death. The results have important implications for the health model centered on PHC and the role of prenatal care in the pregnancy-puerperal cycle. Thus, there is a need to strengthen policies aimed at the pregnancy-puerperal cycle and qualification of the ACN, as a basic activity of the FHS aiming at the prevention of SMM and its complications that impact the lives of women.