title: Factors associated with severe maternal morbidity and near miss in the São Francisco Valley, Brazil: a retrospective, cohort study.
abstract: BACKGROUND
  Maternal mortality remains a major public health issue worldwide, with persistent high rates prevailing principally in underdeveloped countries. The objective of this study was to determine the risk factors for severe maternal morbidity and near miss (SMM/NM) in pregnant and postpartum women at the maternity ward of the Dom Malan Hospital, Petrolina, in northeastern Brazil.
  
  
  METHODS
  A retrospective, cohort study was conducted to evaluate the sociodemographic and obstetric characteristics of the women. Patients who remained hospitalized at the end of the study period were excluded. Risk ratios (RR) and their respective 95% confidence intervals (95% CI) were calculated as a measure of relative risk. Hierarchical multiple logistic regression was also performed. Two-tailed p-values were used for all the tests and the significance level adopted was 5%.
  
  
  RESULTS
  A total of 2,291 pregnant or postpartum women receiving care between May and August, 2011 were included. The frequencies of severe maternal morbidity and near miss were 17.5% and 1.0%, respectively. Following multivariate analysis, the factors that remained significantly associated with an increased risk of SMM/NM were a Cesarean section in the current pregnancy (OR: 2.6; 95% CI: 2.0 - 3.3), clinical comorbidities (OR: 3.4; 95% CI: 2.5 - 4.4), having attended fewer than six prenatal visits (OR: 1.1; 95% CI: 1.01 - 1.69) and the presence of the third delay (i.e. delay in receiving care at the health facility) (OR: 13.3; 95% CI: 6.7 - 26.4).
  
  
  CONCLUSIONS
  The risk of SMM/NM was greater in women who had been submitted to a Cesarean section in the current pregnancy, in the presence of clinical comorbidities, fewer prenatal visits and when the third delay was present. All these factors could be minimized by initiating a broad debate on healthcare policies, introducing preventive measures and improving the training of the professionals and services providing obstetric care.
authors.forename: Alvaro José Correia
authors.initials: AJ
authors.lastname: Pacheco
authors.affiliation: Postgraduate Program, Instituto de Medicina Integral Prof, Fernando Figueira (IMIP), Rua dos Coelhos, 300, Boa Vista, 50,070-902 Recife, PE, Brazil. katzleila@gmail.com.
authors.forename: Leila
authors.initials: L
authors.lastname: Katz
authors.forename: Alex Sandro Rolland
authors.initials: AS
authors.lastname: Souza
authors.forename: Melania Maria Ramos
authors.initials: MM
authors.lastname: de Amorim
mesh_terms: D000328:Adult; D001938:Brazil / Q000453:epidemiology; D016001:Confidence Intervals; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008428:Maternal Mortality / Q000639:trends; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D014505:Urban Population; D055815:Young Adult