Resumen de Mortalidad materna y morbilidad materna grave en la Comunitat Valenciana (2006-2010)
- español
Antecedentes: La mortalidad materna (MM) es un indicador clave para medir el estado de salud de una población. En los países desarrollados, las muertes maternas son eventos infrecuentes y el estudio de la morbilidad materna grave (MMG) aporta información útil para mejorar la calidad de la atención y los resultados en salud. El objetivo ha sido determinar la magnitud y los determinantes de la mortalidad materna y morbilidad materna grave en la Comunitat Valenciana (CV), España.
Método: Estudio observacional transversal. La población de estudio fueron las mujeres en edad fértil, que estuvieron embarazadas entre el 1/1/2006 y el 31/12/2010. Las fuentes de información fueron el Registro de Mortalidad, Boletín Estadístico de Parto, Conjunto Mínimo de Datos de Altas Hospitalarias, Registro de Metabolopatías y el Sistema de Información Poblacional. Se identificaron las muertes maternas ocurridas durante la gestación o en el año posterior a su finalización mediante el enlace entre registros y la revisión de los casos por un panel de expertos. Se examinaron las altas hospitalarias con morbilidad grave, seleccionando aquellos casos en los que existía una causa obstétrica manifiesta y revisando el resto con el fin de determinar la existencia de una relación con la gestación (casos de MMG). Se estimó el subregistro de la MM en las estadísticas oficiales, se realizó un análisis descriptivo de las muertes maternas y se calculó la razón de mortalidad materna (RMM) y su intervalo de confianza al 95% (IC95%). Se realizó un análisis descriptivo de los casos de MMG y una regresión logística con el cálculo de las OR ajustadas (ORa) y sus IC95%. Resultados: Se identificaron 31 muertes maternas (22,6% de defunciones tardías), con un subregistro del 74,2%, que afectaba sobre todo a las muertes de causa indirecta. La RMM global fue de 11,83 por 100.000 nacidos vivos. Un 41,9% de las muertes fueron de causa directa y un 58,1% indirecta. Las principales causas de MM directa fueron la hemorragia obstétrica y los trastornos hipertensivos del embarazo. Las enfermedades infecciosas y los tumores malignos fueron las causas indirectas más frecuentes. La proporción de casos de MMG fue de 3 por 1.000 episodios reproductivos. La rotura uterina, los trastornos hipertensivos del embarazo, el shock y la hemorragia obstétrica fueron las complicaciones más frecuentes, aunque se apreciaron diferencias según el resultado de la gestación, la distribución temporal y el país de nacimiento de la mujer. El riesgo de MMG fue superior en los episodios reproductivos en mujeres de ¿35 años, en las nacidas en África Subsahariana o América Central o del Sur, en las residentes en Castellón, en los embarazos ectópicos y en los casos con antecedentes de hipertensión arterial, obesidad o diabetes. Además, la gestación múltiple y el antecedente obstétrico de cesárea se asociaron a un riesgo mayor de MMG en los partos.
Conclusiones: La integración de sistemas de información junto con la revisión de casos por expertos favorece el análisis exhaustivo de la MM, mejora la información sobre las defunciones de causa indirecta y permite incorporar las muertes tardías. El análisis de la MMG ofrece un conocimiento más amplio de los determinantes de la salud materna y evidencia la existencia de desigualdades en función de la edad, área geográfica de nacimiento y lugar de residencia de la mujer, así como un riesgo mayor de complicaciones graves en las gestaciones múltiples, cesárea previa y presencia de comorbilidad materna.
- English
Background and objective: Maternal mortality (MM) is a key indicator to measure the health status of a population. In developed countries, where maternal deaths are uncommon events, studying severe maternal morbidity (SMM) may provide useful information in order to improve the quality of care and health outcomes. The objective of this study has been to determine the magnitude and determinants of maternal mortality and severe maternal morbidity in resident women of the Valencian Community (VC), Spain, during the period 2006-2010, identifying and incorporating late maternal deaths and morbidity cases.
Method: Observational cross-sectional study. The studied population was constituted by women of childbearing age that became pregnant between 01/01/2006 and 31/12/2010, regardless of the pregnancy result. The sources of information used in this work were the Register of Mortality, Statistical Birth Bulletin, Minimun Basic Data Set of Hospital Admissions, Register of Metabolopathies and the Population Information System. Deaths occurred during the pregnancy or one year after its finalization were identified by linkage among registers, using as common variable the personal identification number of the health insurance card. Subsequently, a panel of experts constituted by 6 obstetricians classified deceases in deaths related to pregnancy (maternal deaths), from a direct or indirect cause, and non-related deaths. A list of diseases, processes or interventions indicating severe maternal morbidity was elaborated, along with codes of the International Classification of Diseases, Review 9, Clinical Modification. Hospital discharges which presented one of them were identified, selecting those cases in which there was an evident obstetric cause and checking the rest in order to determine the existence of a relation with pregnancy (SMM cases). A descriptive analysis of maternal deaths was carried out and maternal mortality ratio (MMR) and its 95% Confidence Interval (CI95%) were calculated. Besides, an underreporting of MM in official statistics was estimated. A descriptive analysis of reproductive events and SMM cases was made. To determine the entire effect of the different considered variables in this study, a logistic regression was accomplished with the adjusted OR calculation (ORa) and its CI95%.
Results: 31 maternal deaths were identified (22.6% were late deceases), with an underreporting of 74.2% in official mortality statistics that affected mainly indirect deaths. The MMR, considering all deaths related to pregnancy, increased to 11.83 per 100,000 live births (CI95%: 7.67-16.00). 41.9% of deaths resulted from a direct cause and 58.1% from an indirect cause. The main direct causes of maternal death were obstetric haemorrhages and hypertensive disorders in pregnancy. Infectious diseases and malignant tumors were the most usual indirect causes. MMR was higher in women aged 35 or older (MMR=1.32; CI95%: 5.45-23.20) and in Spanish women (MMR=12.60; CI95%: 7.66-17.54), not being these differences statistically significant. In public hospitals from VC, between 2006 and 2010, 226,010 pregnancies were looked after. Among them, 993 were molar pregnancies, 3,023 ectopic pregnancies, 23,116 abortions or miscarriages and 198,878 were live births or stillbirths. The SMM ratio was 3 per 1,000 reproductive events. Uterine rupture, hypertensive disorders in pregnancy, shock and obstetric haemorrhage were the most common complications, even if, depending on the pregnancy outcome, timing and country of birth, differences were appreciated. SMM risk was higher in reproductive events of women aged 35 or older (ORa=1.49; CI95%: 1.26-1.77), born in Sub-Saharan Africa (ORa=2.64; CI95%: 1.70-4.11) or Central or South America (ORa=1.46; CI95%:1.16-1.83), residents in Castellón (ORa=1.45; CI95%: 1.14- 1.84) and in ectopic pregnancies (ORa=4.26; CI95%: 2.35-7.72), also in cases with a history of high blood pressure (ORa=2.86; CI95%: 1.51-5.42), obesity (ORa=4.11; CI95%: 2.23-7.58), or pregestational diabetes (ORa=3.44; CI95%: 1.52-7.79). Besides that, multiple pregnancy (ORa=3.28; CI95%: 2.36-4.56) and previous caesarean section (ORa=2.83; CI95%: 2.31-3.48) were associated to a higher risk of SMM in deliveries.
Conclusions: The integration of information systems along with the cases revision by a committee of experts favors the exhaustive analysis of maternal mortality, improves the information about indirect deaths and allows including late deaths related to pregnancy. The severe maternal morbidity analysis offers a wide knowledge of maternal health determinants and it has already brought to light the existence of inequalities according to women’s age, geographical area of birth and residence place, and even a higher risk of severe complications in multiple pregnancies, in women with previous caesarean section and maternal comorbidity.
