{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T16:18:06Z","timestamp":1780676286752,"version":"3.54.1"},"reference-count":23,"publisher":"Federa\u00e7\u00e3o das Associa\u00e7\u00f5es de Ginecologia e Obstetr\u00edcia","issue":"03","license":[{"start":{"date-parts":[[2018,4,2]],"date-time":"2018-04-02T00:00:00Z","timestamp":1522627200000},"content-version":"vor","delay-in-days":32,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Rev Bras Ginecol Obstet"],"published-print":{"date-parts":[[2018,3]]},"abstract":"<jats:p>Objective\u2003The aim of this study is to evaluate the burden of indirect causes of maternal morbidity\/mortality in Brazil.<\/jats:p><jats:p>Methods\u2003Secondary analysis of a multicenter cross-sectional study conducted in 27 referral obstetric units within the Brazilian Network for Surveillance of Severe Maternal Morbidity.<\/jats:p><jats:p>Results\u2003A total of 82,388 women were surveilled: 9,555 women with severe maternal morbidity were included, and 942 (9.9%) of them had indirect causes of morbidity\/mortality. There was an increased risk of higher severity among the indirect causes group, which presented 7.56 times increased risk of maternal death (prevalence ratio [PR]: 7.56; 95% confidence interval [95%CI]: 4.99\u201311.45). The main indirect causes of maternal death were H1N1 influenza, sepsis, cancer and cardiovascular disease. Non-public antenatal care (PR: 2.52; 95%CI: 1.70\u20133.74), diabetes (PR: 1.90; 95%CI: 1.24\u20132.90), neoplasia (PR: 1.98; 95%CI: 1.25\u20133.14), kidney diseases (PR: 1.99; 95%CI: 1.14\u20133.49), sickle cell anemia (PR: 2.50; 95%CI: 1.16\u20135.41) and drug addiction (PR: 1.98; 95%CI: 1.03\u20133.80) were independently associated with worse results in the indirect causes group. Some procedures for the management of severity were more common for the indirect causes group.<\/jats:p><jats:p>Conclusion\u2003Indirect causes were present in less than 10% of the overall cases, but they represented over 40% of maternal deaths in the current study. Indirect causes of maternal morbidity\/mortality were also responsible for an increased risk of higher severity, and they were associated with worse maternal and perinatal outcomes. In middle-income countries there is a mix of indirect causes of maternal morbidity\/mortality that points to some advances in the scale of obstetric transition, but also reveals the fragility of health systems.<\/jats:p>","DOI":"10.1055\/s-0038-1623511","type":"journal-article","created":{"date-parts":[[2018,4,2]],"date-time":"2018-04-02T22:34:50Z","timestamp":1522708490000},"page":"106-114","source":"Crossref","is-referenced-by-count":17,"title":["The Burden of Indirect Causes of Maternal Morbidity and Mortality in the Process of Obstetric Transition: A Cross-Sectional Multicenter Study"],"prefix":"10.61622","volume":"40","author":[{"given":"Jessica Fernandes","family":"Cirelli","sequence":"additional","affiliation":[{"name":"Department of Obsterics and Gynecology, School of Medical Science, Universidade Estadual de Campinas, Campinas, S\u00e3o Paulo, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernanda Garanhani","family":"Surita","sequence":"additional","affiliation":[{"name":"Department of Obsterics and Gynecology, School of Medical Science, Universidade Estadual de Campinas, Campinas, S\u00e3o Paulo, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Laura","family":"Costa","sequence":"additional","affiliation":[{"name":"Department of Obsterics and Gynecology, School of Medical Science, Universidade Estadual de Campinas, Campinas, S\u00e3o Paulo, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary Angela","family":"Parpinelli","sequence":"additional","affiliation":[{"name":"Department of Obsterics and Gynecology, School of Medical Science, Universidade Estadual de Campinas, Campinas, S\u00e3o Paulo, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samira Maerrawi","family":"Haddad","sequence":"additional","affiliation":[{"name":"Department of Obsterics and Gynecology, School of Medical Science, 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