title: The role of infection and sepsis in the Brazilian Network for Surveillance of Severe Maternal Morbidity.
abstract: OBJECTIVE
  To identify the burden of severe infection within the Brazilian Network for Surveillance of Severe Maternal Morbidity and factors associated with worse maternal outcomes.
  
  
  METHODS
  This was a multicentre cross-sectional study involving 27 referral maternity hospitals in Brazil. WHO's standardised criteria for potentially life-threatening conditions and maternal near miss were used to identify cases through prospective surveillance and the main cause of morbidity was identified as infection or other causes (hypertension, haemorrhage or clinical/surgical). Complications due to infection were compared to complications due to the remaining causes of morbidity. Factors associated with a severe maternal outcome were assessed for the cases of infection.
  
  
  RESULTS
  A total of 502 (5.3%) cases of maternal morbidity were associated with severe infection vs. 9053 cases (94.7%) with other causes. Considering increased severity of cases, infection was responsible for one-fourth of all maternal near miss (23.6%) and nearly half (46.4%) of maternal deaths, with a maternal near miss to maternal death ratio three times (2.8:1) that of cases without infection (7.8:1) and a high mortality index (26.3%). Within cases of infection, substandard care was present in over one half of the severe maternal outcome cases. Factors independently associated with worse maternal outcomes were HIV/AIDS, hysterectomy, prolonged hospitalisation, intensive care admission and delays in medical care.
  
  
  CONCLUSIONS
  Infection is an alarming cause of maternal morbidity and mortality and timely diagnosis and adequate management are key to improving outcomes during pregnancy. Delays should be addressed, risk factors identified, and specific protocols of surveillance and care developed for use during pregnancy.
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.
authors.forename: L C
authors.initials: LC
authors.lastname: Pfitscher
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.
authors.forename: J G
authors.initials: JG
authors.lastname: Cecatti
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.
authors.forename: S M
authors.initials: SM
authors.lastname: Haddad
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.
authors.forename: M A
authors.initials: MA
authors.lastname: Parpinelli
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.|Department of Obstetrics and Gynecology, University of São Paulo in Ribeirao Preto, São Paulo, Brazil.
authors.forename: J P
authors.initials: JP
authors.lastname: Souza
authors.affiliation: Department of Obstetrics and Gynecology, University of São Paulo in Ribeirao Preto, São Paulo, Brazil.
authors.forename: S M
authors.initials: SM
authors.lastname: Quintana
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.
authors.forename: F G
authors.initials: FG
authors.lastname: Surita
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, São Paulo, Brazil.
authors.forename: M L
authors.initials: ML
authors.lastname: Costa
mesh_terms: D001938:Brazil / Q000453:epidemiology; D003422:Critical Care; D003430:Cross-Sectional Studies; D005260:Female; D006771:Hospitals, Maternity / Q000592:standards; D006801:Humans; D007239:Infections / Q000453:epidemiology* / Q000401:mortality; D007902:Length of Stay; D063130:Maternal Death / Q000209:etiology*; D008428:Maternal Mortality; D009017:Morbidity; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology* / Q000401:mortality; D011295:Prenatal Care / Q000592:standards; D011446:Prospective Studies; D011787:Quality of Health Care; D012307:Risk Factors; D018805:Sepsis / Q000453:epidemiology / Q000401:mortality; D012720:Severity of Illness Index
keywords: décès maternels évités de justesse; infección; infection; maternal mortality; maternal near miss; morbidité maternelle sévère et aiguë; morbilidad materna extrema; morbilidad maternal aguda severa; mortalidad materna; mortalité maternelle; sepsis; septicémie; severe acute maternal morbidity