In the United Nations' 2000 declaration of the Millennium Development Goals, improvement of maternal health was regarded as an essential prerequisite for human development and for poverty reduction (1). Although pregnancy is a normal life-course event that most women aspire to at some point in their lives, about eight million women develop pregnancy-related complications every year, and of them, over half a million die (2). Even in the context of limited resources, most of these deaths could be avoided if preventive measures were taken and adequate care was available (1). However, the right kind of information on which maternal mortality-prevention strategies are based is often missing (2).
In Brazil, deaths are registered in the national mortality information system (SIM) of the Ministry of Health. Its coverage has been systematically increasing since its inception in 1976, reaching 82% nationwide by 1999, albeit with marked regional variation. Of all the registered deaths, maternal deaths are particularly problematic, mainly due to inadequate assignment of causes of death in death certificates.
As a strategy to improve the registration of maternal deaths, starting in 1994, the Ministry of Health of Brazil has encouraged the creation of the Perinatal and Maternal Mortality Investigation Committees at both State and County Health Departments (3). Moreover, information on pregnancy, abortion, parturition, or puerperium in all women of reproductive age at death has been added to both national death certificate form and SIM. In addition, maternal death reporting to the public-health surveillance system within 24 hours after demise has been mandated (4).
In 2002, a nationwide study of maternal mortality was carried out in most Brazilian state capitals (5). Based on household interviews and investigation of medical and hospital records and autopsies (the Reproductive Age Mortality Study methodology-RAMOS), the maternal mortality ratios (MMRs) were estimated, which were lower than the values reported by the World Health Organization (WHO), United Nations Children's Fund, and United Nations Population Fund. The estimated MMR adjustment factor for official data in Brazil was equal to 1.4--representing a 40% under-registration of maternal deaths--based upon which the adjusted MMR was 54.3 maternal deaths per 100,000 livebirths. The authors highlighted the heterogeneous validity of data on maternal mortality across Brazilian regions: quality of data was poorer in the north and northeast regions compared to the south and southeast regions where validity was higher. Direct obstetric causes accounted for 67.1% of all maternal deaths, suggesting that both prenatal and childbirth care must be improved.
As the epidemiological assessment of maternal mortality is important in revising old and developing new public-health strategies of prevention, we analyzed maternal deaths according to demographic, educational and obstetric characteristics in the city of Rio de Janeiro from 2000 to 2003.
MATERIALS AND METHODS
The study was conducted in the city of Rio de Janeiro, the capital of Rio de Janeiro state, situated in the southeast region of Brazil. In 2000, the city had a population of 5,857,904 inhabitants; the average number of livebirths per woman in reproductive ages (15-49 years) was 1.8 (6), and 99% occurred in hospital settings (7).
Data on maternal mortality were obtained from the SIM and from records provided by the Perinatal and Maternal Mortality Investigation Committee (PMMIC) of the city of Rio de Janeiro. Livebirth data were collected from the national livebirth information system (SINASC). Both information systems--SIM and SINASC--have high coverage within the state of Rio de Janeiro (8).
The WHO defines maternal death as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. …