Morbimortalidade Materna e a associaccedilatildeo com as Demoras na obtenccedilatildeo dos

cuidados obsteacutetricos

1ordm Encontro dos Comitecircs Regionais de Vigilacircncia agrave Morte Materna e Infantil do Estado de Satildeo Paulo

Samira El Maerrawi T Haddad

2013

2

Mortes Maternas

Em meados da deacutecada de 80

ldquoBaixo Nuacutemerordquo

Gecircnero

Lifetime Risk

1 em 26 1 em 7300

Risco 280 vezes

maior

Risco 280 vezes

maior

Socioeconocircmica

O impacto social econocircmico e de sauacutede desse cenaacuterio tornou a reduccedilatildeo

da morte materna e do receacutem-nascido a mais urgente prioridade

para o desenvolvimento do milecircnio

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

2

Mortes Maternas

Em meados da deacutecada de 80

ldquoBaixo Nuacutemerordquo

Gecircnero

Lifetime Risk

1 em 26 1 em 7300

Risco 280 vezes

maior

Risco 280 vezes

maior

Socioeconocircmica

O impacto social econocircmico e de sauacutede desse cenaacuterio tornou a reduccedilatildeo

da morte materna e do receacutem-nascido a mais urgente prioridade

para o desenvolvimento do milecircnio

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

ldquoBaixo Nuacutemerordquo

Gecircnero

Lifetime Risk

1 em 26 1 em 7300

Risco 280 vezes

maior

Risco 280 vezes

maior

Socioeconocircmica

O impacto social econocircmico e de sauacutede desse cenaacuterio tornou a reduccedilatildeo

da morte materna e do receacutem-nascido a mais urgente prioridade

para o desenvolvimento do milecircnio

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Gecircnero

Lifetime Risk

1 em 26 1 em 7300

Risco 280 vezes

maior

Risco 280 vezes

maior

Socioeconocircmica

O impacto social econocircmico e de sauacutede desse cenaacuterio tornou a reduccedilatildeo

da morte materna e do receacutem-nascido a mais urgente prioridade

para o desenvolvimento do milecircnio

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Lifetime Risk

1 em 26 1 em 7300

Risco 280 vezes

maior

Risco 280 vezes

maior

Socioeconocircmica

O impacto social econocircmico e de sauacutede desse cenaacuterio tornou a reduccedilatildeo

da morte materna e do receacutem-nascido a mais urgente prioridade

para o desenvolvimento do milecircnio

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

O impacto social econocircmico e de sauacutede desse cenaacuterio tornou a reduccedilatildeo

da morte materna e do receacutem-nascido a mais urgente prioridade

para o desenvolvimento do milecircnio

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Mortalidade Materna no Mundo

Evoluccedilatildeo entre 1990 ndash 2010

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

O potencial de prediccedilatildeo e prevenccedilatildeo da complicaccedilatildeo obsteacutetrica eacute baixo

As complicaccedilotildees durante o parto

ocorrem mesmo nas melhores condiccedilotildees de vida

A maioria das mulheres com fatores de risco

natildeo teraacute problemas durante o parto

A maioria das complicaccedilotildees graves

ocorre em mulheres sem fatores de risco reconhecidos

(Rooks et al 1989 Loudon 1986 Kaunitz et al 1984)

8

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Transiccedilatildeo do foco de atenccedilatildeo

Continuum de Morbidade Materna

ComplicaccedilatildeoComplicaccedilatildeo dada

GestaccedilatildeoGestaccedilatildeo

ComplicaccedilatildeoComplicaccedilatildeo GraveGrave

GestaccedilatildeoGestaccedilatildeo NormalNormal

OacutebitoOacutebito

Disfunccedilatildeo Disfunccedilatildeo

FalecircnciaFalecircncia

15

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Mulheres que morrem por complicaccedilotildees da gravidez chegavam agraves instituiccedilotildees de referecircncia em condiccedilotildees tatildeo

graves que dificilmente poderiam ser salvas

TOO FAR TO WALK Maternal Mortality in Context

(findings from a Multidisciplinary literature review)

By

Thaddeus S Maine D1990

O TEMPO na obtenccedilatildeo de cuidados adequados eacute o fator mais

importante relacionado agraves mortes maternas

CUIDADOS OBSTEacuteTRICOS DE EMERGEcircNCIA - EmOC

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

ldquoThe three delays Modelrdquo

11

Fase I

Demora na decisatildeo de procurar

cuidado

Fase III

Demora em receber os cuidados

adequados

Fase II

Demora em chegar a uma unidade de

sauacutede

DistacircnciaCusto

QualidadeGravidade do quadroGecircneroDependecircncia

Socioeconocircmicas

Serviccedilos de referecircnciaUBS

Drogas e equipamentosProtocolos

RH (treinamentoqualificaccedilatildeo)Infraestrutura

Manejo inadequadoBurocracia

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

12

Mortes Maternas

Morbidade Materna Grave

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Severe acute maternal morbidity a pilot

study of a definition for a near-miss

Mantel GD Buchmann E Rees H

Pattinson RC

Morbidade Materna Grave

Estudos no Mundo

Best Pract Res Clin Obstet Gynaecol 2009 Jun23(3)287-96 Epub 2009 Mar 19

Maternal near missMaternal near miss----towards a standard tool towards a standard tool for monitoring quality of for monitoring quality of

maternal health carematernal health careSay L Souza JP Pattinson RC WHO working group on Maternal Mortality and Morbidity

classifications

Morbidade Materna Grave

Near Miss

Near Miss

Incidente natildeo ocorreu por ACASO

ou porque medidas foram realizadas

OPORTUNAMENTE

CRITEacuteRIOS CLIacuteNICOS

Cianose aguda

Gasping

Frequecircncia respiratoacuteria gt 40 ou lt 6

Choque

Oliguacuteria natildeo responsiva a fluidos ou

diureacuteticos

Distuacuterbio de coagulaccedilatildeo

Perda de consciecircncia durante 12h ou

mais

Ausecircncia de consciecircncia e ausecircncia

de pulsobatimento cardiacuteaco

Acidente vascular cerebral

Convulsatildeo natildeo controlada Paralisia

total

Icteriacutecia na presenccedila de preacute-

eclacircmpsia

CRITEacuteRIOS LABORATORIAIS

Saturaccedilatildeo de oxigecircnio lt90 por

gt60 minutos

PaO2 FiO2 lt 200

Creatinina ge 300mmoll ou ge 35

mgdl

Bilirrubina ge 100 mmoll ou ge 60

mgdl

pH lt 71

Lactato gt 5

Trombocitopenia aguda (lt 50 000

plaquetas)

Ausecircncia de consciecircncia e presenccedila

de glicose e cetoacidose na urina

CRITEacuteRIOS DE MANEJO

Uso de droga vasoativa continua

Histerectomia puerperal por

infecccedilatildeo ou hemorragia

Transfusatildeo de ge 5 unidades de

concentrado de hemaacutecias

Intubaccedilatildeo e ventilaccedilatildeo por tempo ge

60 minutos natildeo relacionada com

anestesia

Diaacutelise para insuficiecircncia renal

aguda

Ressuscitaccedilatildeo Cardiopulmonar

(RCP)

Near Miss

Condiccedilotildees potencialmente ameaccediladoras da

vida

COMPLICACcedilOtildeES HEMORRAacuteGICAS

Descolamento prematuro de placenta

Placenta preacutevia acretaincretapercreta

Prenhez ectoacutepica

Rotura uterina

Hemorragia grave por aborto

Hemorragia poacutes parto

a) Atonia

b) Retenccedilatildeo placentaacuteria

c) Laceraccedilotildees de trajeto

d) Coagulopatia

COMPLICACcedilOtildeES HIPERTENSIVAS

Preacute-eclacircmpsia grave

Eclacircmpsia

Hipertensatildeo grave

HELLP siacutendrome

OUTRAS COMPLICACcedilOtildeES

Edema pulmonar

Convulsotildees

Sepse grave

a) Endometrite poacutes parto

b) Endometrite poacutes aborto

c) Foco urinaacuterio

d) Foco pulmonar

Trombocitopenia lt 100 mil

Crise tireotoacutexica

Choque

Insuficiecircncia respiratoacuteria aguda

Acidose

Cardiopatia

AVC

Distuacuterbios de coagulaccedilatildeo

Tromboembolismo

Cetoacidose diabeacutetica

Icteriacutecia disfunccedilatildeo hepaacutetica

Meningite

Insuficiecircncia Renal Aguda

INDICADORES DE MANEJO DE GRAVIDADE

Transfusatildeo de hemoderivados

Acesso venoso central

Admissatildeo em UTI

Hospitalizaccedilatildeo prolongada (gt7dias)

Intubaccedilatildeo natildeo relacionada agrave anestesia

Retorno agrave sala ciruacutergica

Intervenccedilatildeo ciruacutergica maior (histerectomia

laparotomia)

Uso de sulfato de magneacutesio

Vigilacircncia da Morbimortalidade materna

Vigilacircncia da Morbimortalidade materna

Percursos e demoras semelhantes agraves mulheres que morreram

Complementaccedilatildeo dos registros meacutedicos Auditoria + Entrevista

Maior entendimento de como as mulheres vivenciam o

cuidado obsteacutetrico

Obtenccedilatildeo de informaccedilotildees das proacuteprias mulheres apoacutes o evento

Chave para avaliaccedilatildeo da qualidade da assistecircnciaIndicador da eficaacutecia dos encaminhamentos de emergecircncia

Ferramenta para monitorar o desempenho dos serviccedilos obsteacutetricos

20

Demoras e Near miss

Filippi 2005 Okong et al 2006 Oladapo et al 2007 Adisasmita et al 2008 Ronsmans 2009 Roumloumlst Altamirano et al 2009 Filippi Richard et al 2009 Souza Cecatti et al 2009 Hirose et al 2010 Lori e Starke 2011 Kaye et al 2011 Morseet al 2011 Amaral Souza et al 2011

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

CRITEacuteRIOS CLIacuteNICOS

Cianose aguda

Gasping

Frequecircncia respiratoacuteria gt 40 ou lt 6

Choque

Oliguacuteria natildeo responsiva a fluidos ou

diureacuteticos

Distuacuterbio de coagulaccedilatildeo

Perda de consciecircncia durante 12h ou

mais

Ausecircncia de consciecircncia e ausecircncia

de pulsobatimento cardiacuteaco

Acidente vascular cerebral

Convulsatildeo natildeo controlada Paralisia

total

Icteriacutecia na presenccedila de preacute-

eclacircmpsia

CRITEacuteRIOS LABORATORIAIS

Saturaccedilatildeo de oxigecircnio lt90 por

gt60 minutos

PaO2 FiO2 lt 200

Creatinina ge 300mmoll ou ge 35

mgdl

Bilirrubina ge 100 mmoll ou ge 60

mgdl

pH lt 71

Lactato gt 5

Trombocitopenia aguda (lt 50 000

plaquetas)

Ausecircncia de consciecircncia e presenccedila

de glicose e cetoacidose na urina

CRITEacuteRIOS DE MANEJO

Uso de droga vasoativa continua

Histerectomia puerperal por

infecccedilatildeo ou hemorragia

Transfusatildeo de ge 5 unidades de

concentrado de hemaacutecias

Intubaccedilatildeo e ventilaccedilatildeo por tempo ge

60 minutos natildeo relacionada com

anestesia

Diaacutelise para insuficiecircncia renal

aguda

Ressuscitaccedilatildeo Cardiopulmonar

(RCP)

Near Miss

Condiccedilotildees potencialmente ameaccediladoras da

vida

COMPLICACcedilOtildeES HEMORRAacuteGICAS

Descolamento prematuro de placenta

Placenta preacutevia acretaincretapercreta

Prenhez ectoacutepica

Rotura uterina

Hemorragia grave por aborto

Hemorragia poacutes parto

a) Atonia

b) Retenccedilatildeo placentaacuteria

c) Laceraccedilotildees de trajeto

d) Coagulopatia

COMPLICACcedilOtildeES HIPERTENSIVAS

Preacute-eclacircmpsia grave

Eclacircmpsia

Hipertensatildeo grave

HELLP siacutendrome

OUTRAS COMPLICACcedilOtildeES

Edema pulmonar

Convulsotildees

Sepse grave

a) Endometrite poacutes parto

b) Endometrite poacutes aborto

c) Foco urinaacuterio

d) Foco pulmonar

Trombocitopenia lt 100 mil

Crise tireotoacutexica

Choque

Insuficiecircncia respiratoacuteria aguda

Acidose

Cardiopatia

AVC

Distuacuterbios de coagulaccedilatildeo

Tromboembolismo

Cetoacidose diabeacutetica

Icteriacutecia disfunccedilatildeo hepaacutetica

Meningite

Insuficiecircncia Renal Aguda

INDICADORES DE MANEJO DE GRAVIDADE

Transfusatildeo de hemoderivados

Acesso venoso central

Admissatildeo em UTI

Hospitalizaccedilatildeo prolongada (gt7dias)

Intubaccedilatildeo natildeo relacionada agrave anestesia

Retorno agrave sala ciruacutergica

Intervenccedilatildeo ciruacutergica maior (histerectomia

laparotomia)

Uso de sulfato de magneacutesio

Vigilacircncia da Morbimortalidade materna

Vigilacircncia da Morbimortalidade materna

Percursos e demoras semelhantes agraves mulheres que morreram

Complementaccedilatildeo dos registros meacutedicos Auditoria + Entrevista

Maior entendimento de como as mulheres vivenciam o

cuidado obsteacutetrico

Obtenccedilatildeo de informaccedilotildees das proacuteprias mulheres apoacutes o evento

Chave para avaliaccedilatildeo da qualidade da assistecircnciaIndicador da eficaacutecia dos encaminhamentos de emergecircncia

Ferramenta para monitorar o desempenho dos serviccedilos obsteacutetricos

20

Demoras e Near miss

Filippi 2005 Okong et al 2006 Oladapo et al 2007 Adisasmita et al 2008 Ronsmans 2009 Roumloumlst Altamirano et al 2009 Filippi Richard et al 2009 Souza Cecatti et al 2009 Hirose et al 2010 Lori e Starke 2011 Kaye et al 2011 Morseet al 2011 Amaral Souza et al 2011

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Condiccedilotildees potencialmente ameaccediladoras da

vida

COMPLICACcedilOtildeES HEMORRAacuteGICAS

Descolamento prematuro de placenta

Placenta preacutevia acretaincretapercreta

Prenhez ectoacutepica

Rotura uterina

Hemorragia grave por aborto

Hemorragia poacutes parto

a) Atonia

b) Retenccedilatildeo placentaacuteria

c) Laceraccedilotildees de trajeto

d) Coagulopatia

COMPLICACcedilOtildeES HIPERTENSIVAS

Preacute-eclacircmpsia grave

Eclacircmpsia

Hipertensatildeo grave

HELLP siacutendrome

OUTRAS COMPLICACcedilOtildeES

Edema pulmonar

Convulsotildees

Sepse grave

a) Endometrite poacutes parto

b) Endometrite poacutes aborto

c) Foco urinaacuterio

d) Foco pulmonar

Trombocitopenia lt 100 mil

Crise tireotoacutexica

Choque

Insuficiecircncia respiratoacuteria aguda

Acidose

Cardiopatia

AVC

Distuacuterbios de coagulaccedilatildeo

Tromboembolismo

Cetoacidose diabeacutetica

Icteriacutecia disfunccedilatildeo hepaacutetica

Meningite

Insuficiecircncia Renal Aguda

INDICADORES DE MANEJO DE GRAVIDADE

Transfusatildeo de hemoderivados

Acesso venoso central

Admissatildeo em UTI

Hospitalizaccedilatildeo prolongada (gt7dias)

Intubaccedilatildeo natildeo relacionada agrave anestesia

Retorno agrave sala ciruacutergica

Intervenccedilatildeo ciruacutergica maior (histerectomia

laparotomia)

Uso de sulfato de magneacutesio

Vigilacircncia da Morbimortalidade materna

Vigilacircncia da Morbimortalidade materna

Percursos e demoras semelhantes agraves mulheres que morreram

Complementaccedilatildeo dos registros meacutedicos Auditoria + Entrevista

Maior entendimento de como as mulheres vivenciam o

cuidado obsteacutetrico

Obtenccedilatildeo de informaccedilotildees das proacuteprias mulheres apoacutes o evento

Chave para avaliaccedilatildeo da qualidade da assistecircnciaIndicador da eficaacutecia dos encaminhamentos de emergecircncia

Ferramenta para monitorar o desempenho dos serviccedilos obsteacutetricos

20

Demoras e Near miss

Filippi 2005 Okong et al 2006 Oladapo et al 2007 Adisasmita et al 2008 Ronsmans 2009 Roumloumlst Altamirano et al 2009 Filippi Richard et al 2009 Souza Cecatti et al 2009 Hirose et al 2010 Lori e Starke 2011 Kaye et al 2011 Morseet al 2011 Amaral Souza et al 2011

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Vigilacircncia da Morbimortalidade materna

Vigilacircncia da Morbimortalidade materna

Percursos e demoras semelhantes agraves mulheres que morreram

Complementaccedilatildeo dos registros meacutedicos Auditoria + Entrevista

Maior entendimento de como as mulheres vivenciam o

cuidado obsteacutetrico

Obtenccedilatildeo de informaccedilotildees das proacuteprias mulheres apoacutes o evento

Chave para avaliaccedilatildeo da qualidade da assistecircnciaIndicador da eficaacutecia dos encaminhamentos de emergecircncia

Ferramenta para monitorar o desempenho dos serviccedilos obsteacutetricos

20

Demoras e Near miss

Filippi 2005 Okong et al 2006 Oladapo et al 2007 Adisasmita et al 2008 Ronsmans 2009 Roumloumlst Altamirano et al 2009 Filippi Richard et al 2009 Souza Cecatti et al 2009 Hirose et al 2010 Lori e Starke 2011 Kaye et al 2011 Morseet al 2011 Amaral Souza et al 2011

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Vigilacircncia da Morbimortalidade materna

Percursos e demoras semelhantes agraves mulheres que morreram

Complementaccedilatildeo dos registros meacutedicos Auditoria + Entrevista

Maior entendimento de como as mulheres vivenciam o

cuidado obsteacutetrico

Obtenccedilatildeo de informaccedilotildees das proacuteprias mulheres apoacutes o evento

Chave para avaliaccedilatildeo da qualidade da assistecircnciaIndicador da eficaacutecia dos encaminhamentos de emergecircncia

Ferramenta para monitorar o desempenho dos serviccedilos obsteacutetricos

20

Demoras e Near miss

Filippi 2005 Okong et al 2006 Oladapo et al 2007 Adisasmita et al 2008 Ronsmans 2009 Roumloumlst Altamirano et al 2009 Filippi Richard et al 2009 Souza Cecatti et al 2009 Hirose et al 2010 Lori e Starke 2011 Kaye et al 2011 Morseet al 2011 Amaral Souza et al 2011

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Percursos e demoras semelhantes agraves mulheres que morreram

Complementaccedilatildeo dos registros meacutedicos Auditoria + Entrevista

Maior entendimento de como as mulheres vivenciam o

cuidado obsteacutetrico

Obtenccedilatildeo de informaccedilotildees das proacuteprias mulheres apoacutes o evento

Chave para avaliaccedilatildeo da qualidade da assistecircnciaIndicador da eficaacutecia dos encaminhamentos de emergecircncia

Ferramenta para monitorar o desempenho dos serviccedilos obsteacutetricos

20

Demoras e Near miss

Filippi 2005 Okong et al 2006 Oladapo et al 2007 Adisasmita et al 2008 Ronsmans 2009 Roumloumlst Altamirano et al 2009 Filippi Richard et al 2009 Souza Cecatti et al 2009 Hirose et al 2010 Lori e Starke 2011 Kaye et al 2011 Morseet al 2011 Amaral Souza et al 2011

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Exemplo de Aplicaccedilatildeo Praacutetica desses Conceitos

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Exemplo de Aplicaccedilatildeo PraacuteticaRede Nacional de Vigilacircncia de MMG

bull Vigilacircncia Prospectiva

bull De julho de 2009 a Junho de 2010

bull Formulaacuterio padronizado

bull Inserccedilatildeo eletrocircnica dos dados

bull Anaacutelise de consistecircncia em tempo real

bull Visitas teacutecnicas

bull Anaacutelise de consistecircncia apoacutes teacutermino

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

12 meses de coleta de dados em 27 centros

82388 nascidos vivos

- 9555 casos de morbidade materna grave

- CPAV 8645

- Near Miss Materno 770 - 934 NM1000NV (1)

- Mortes Materna 140 - 170100000NV (IC 95 144-201)

- 8 da MM do Brasil

RNVMMGResultados Preliminares

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

- Pacientes e Familiares- Demora em procurar o serviccedilo de Sauacutede- Recusa ao tratamento- Aborto inseguro

- Acessibilidade- Dificuldade geograacutefica- PN ausente ou inadequado- Transporte- Comunicaccedilatildeo entre hospitais e central de vagas

- Qualidade do cuidado- Manejo inadequado- Demora em transferecircncia- Ausecircncia de medicaccedilotildees- Demora no diagnoacutestico- Dificuldade de monitorizaccedilatildeo

RNVMMGPesquisa de Demoras no Atendimento

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

0

10

20

30

40

50

60

70

80

90

PLTC MNM MD

138

292

516

157

304

488

388433

555

520

684

841 Health service

Health professionals

Patientsrelatives

plt 000825

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Fase I

Preacute-natal ausente ou inadequado

Demora na procura

Recusa ao tratamento (alta a pedidoevasatildeo)

26

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Fase II

Sistema de sauacutede

bull comunicaccedilatildeo entre as unidades e as dificuldadescom o transporte

Problemas na referecircncia e transferecircncia dos casos

Satildeo umas das maiores barreiras para se oferecer atendimento obsteacutetrico adequado nas situaccedilotildees de emergecircncia

27

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Fase III

bull As demoras mais importantes foram as relacionados com a conduccedilatildeo dos casos por profissionais de sauacutede

Protocolos de conduta

Falha na humanizaccedilatildeo do processo de cuidadondash (Amaral 2011 Donabedian 2000 Souza 2009 Filippi 2005)

28

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

11 Artigo 3

Research

Applying the near miss approach for the evaluation of obstetric care a

worked example from a multicenter surveillance study

Samira Maerrawi Haddad a Jose Guilherme Cecatti a Joao Paulo Souza b Maria

Helena Sousa c Mary Angela Parpinelli a Maria Laura Costa a for the Brazilian

Network for Surveillance of Severe Maternal Morbidity Group

Submetido ao Bulletin of the World Health Organization

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Razatildeo de Mortalidade Padronizada

bull Nuacutemero de mortes observadas

bull Nuacutemero de oacutebitos esperados de acordo com a gravidade

lt 1 lt

Exemplo de Aplicaccedilatildeo PraacuteticaSimulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado

Obsteacutetrico

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Variaacuteveis Adequado Natildeo Adequado

Estrutura (15x) Ausecircncia de UTI

(25x) Regiotildees N NE e CO

Processo e manejo (2x) Admissatildeo em UTI

pgt005

Simulaccedilatildeo de Avaliaccedilatildeo da Qualidade do Cuidado Obsteacutetrico

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Table 5 Distribution of cases of severe maternal morbidity according to occurrence of delays in obtaining obstetric care and level of performance of care

Level of performance

Adequate Non-adequate psup1

Type of delay related to n () n ()

1 User factors 567 (100) 286 (105) 0886 Delay in seeking health services 303 ( 54) 139 ( 51) 0924 Refusal of treatment 276 ( 49) 150 ( 55) 0664 Unsafe abortion 48 ( 09) 3 ( 01) lt0001 Total 5645 2735 2 Health service accessibility 1945 (344) 961 (350) 0928 Total 5647 2744 Difficulty accessing antenatal care 68 ( 11) 58 ( 21) 0418 Difficulties with transportation cityhospital

54

( 09)

63

( 22)

0058

Total 6029 2819 Absent inadequate antenatal care 1909 (338) 783 (286) 0188 Geographic difficulty in accessing health service

22

( 04)

176

( 64)

lt0001

Total 5645 2735 3 Quality of medical care 1046 (173) 1263 (426) 0012 Total 6039 2962 Absence of blood products 20 ( 03) 37 ( 13) 0013 Lack of medication 67 ( 11) 50 ( 18) 0380 Difficulty in communication between hospital and regulatory center

250

( 41)

529

(188)

0004

Lack of trained staff 127 ( 21) 144 ( 51) 0095 Difficulty in monitoring 180 ( 30) 229 ( 81) 0177 Total 6029 2819 Delay in referraltransfer of the case 143 ( 24) 149 ( 52) 0073 Delay in diagnosis 327 ( 54) 160 ( 56) 0964 Delay in starting treatment 416 ( 69) 186 ( 65) 0926 Improper management of the case 589 ( 97) 629 (218) 0135 Total 6052 2879 Any delay 2750 (483) 1937 (642) 0039 Total 5698 3018 sup1 p-value adjusted for cluster effect

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Consideraccedilotildees Finais

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

Justificativa

34

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

O TEMPO na obtenccedilatildeo de CUIDADOS ADEQUADOS eacute o fator mais importante relacionado agraves mortes maternas

(Thaddeus e Maine 1990) 35

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)

ldquo a systemrsquos failure requires a systemrsquos solution ndash not a temporary remedyrdquo

(WHO World Health Report 2008)