Operationalization of Severe Maternal Morbidity surveillance in administrative databases of the Brazilian public and private health systems: Brazil 2015-2022

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: 1.17 times higher SMM rate in public versus private healthcare

• Primary Outcome: SMM prevalence: 8.51% in public system, 7.30% in private system

• Nnt Or Sensitivity: 22 of 26 WHO PLTC criteria successfully operationalized (84.6% sensitivity for WHO framework)

• Confidence Interval: Not reported in abstract

Clinical Application

Requires robust administrative coding systems and standardized SMM criteria implementation Relevant for Australian maternal health surveillance using AIHW data, though coding systems and healthcare structure differ from Brazil. Could inform development of SMM surveillance using Australian ICD-10-AM codes Pregnant and postpartum women in healthcare systems with administrative databases

Abstract

The study of severe maternal morbidity (SMM) is an important strategy for improving the quality of obstetric care. The objective of this study is to assess SMM cases recorded in the Hospital Information System of the Unified Health System (SIH/SUS), which contains public funded hospitalizations, and in the database of the National Supplementary Health Agency (ANS), which contains hospitalizations paid for by health plans. This is a cross-sectional study using obstetric hospitalizations of women aged 10-49 years from both databases in the period 2015-2022. We assessed SMM cases using the World Health Organization's criteria for potentially life-threatening conditions (PLTC). Of the 26 PLTC criteria, 22 were operationalized through diagnoses during hospitalization, using International Classification of Diseases-10 codes, or medical procedures, using specific codes of each database. We estimated the frequency and odds ratio of death for each isolated criterion, for grouped criteria and for the total number of SMM cases, as well as the frequency of deaths according to the number of SMM criteria. We identified 18,807,757 obstetric hospitalizations in the SIH/SUS and 3,776,986 in the ANS database. The estimated proportion of SMM was 8.51% and 7.30% in SIH/SUS and ANS, respectively. Most cases presented only one criterion. Differences were observed among sectors, with a higher frequency of procedure-based criteria in the ANS database, compatible with the greater availability of resources in private services. The proportion of deaths increased with the increase in the number of criteria, and more severe criteria presented a higher odds ratio of death. The results indicate that it is possible to estimate the number of SMM cases in the country, both in public and private hospitalizations. Continued investment in the quality of recording in both databases are necessary so that the estimates can truly reflect the maternal morbidity of Brazilian women.

References

1. 1.Domingues, R. M. S. M., Dias, M. A. B., Guillen, L. C. T., Pinheiro, R. S., Saraceni, V., & Coeli, C. M. (2026). Operationalization of Severe Maternal Morbidity surveillance in administrative databases of the Brazilian public and private health systems: Brazil 2015-2022. PLoS One. https://doi.org/10.1371/journal.pone.0331544