Vigilância da morbidade materna no Brasil: contribuições para o debate
O artigo Morbimortalidade Materna no Brasil e a Urgência de um Sistema Nacional de Vigilância do Near Miss Materno, de autoria de Ferreira et al. 1, aborda o importante tema da morbidade materna e propõe um sistema nacional de vigilância do near miss materno.
Desde 2011, a Organização Mundial da Saúde (OMS) recomenda o estudo da morbidade materna grave de forma complementar ao estudo do óbito materno, por apresentar os mesmos determinantes e frequência mais elevada, permitindo análises mais robustas 2. Embora a razão de mortalidade materna global seja elevada, óbitos maternos apresentam frequência baixa, principalmente no âmbito dos serviços de saúde e em localidades com baixo número de nascimentos.
No Brasil, 2.389 municípios brasileiros não registraram sequer um óbito materno no período de 2012 a 2020 3, demonstrando que estratégias baseadas apenas na investigação dos óbitos maternos são insuficientes para a formulação de estratégias de promoção da saúde materna e de melhoria do cuidado obstétrico.
Entretanto, a melhor forma de fazer a vigilância da morbidade materna grave e do near miss materno é incerta. Os autores do artigo publicado em CSP 1 propõem duas possíveis abordagens: o uso do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS) e a implantação da notificação de casos no Sistema de Informação de Agravos de Notificação (SINAN).
O SIH/SUS é o único sistema de informações brasileiro que contém dados de morbidade obstétrica durante internações hospitalares. Embora seja um sistema formulado para o pagamento de internações, tem sido utilizado para a vigilância do near miss materno; porém, com limitações.
Nakamura-Pereira et al. 4, em estudo realizado no Rio de Janeiro, mostraram que a sensibilidade e o valor preditivo positivo do SIH/SUS foram baixos para a detecção de casos de near miss materno. Esse resultado é, de alguma forma, esperado, já que, dos 25 critérios de disfunção orgânica recomendados pela OMS para classificação de casos de near miss materno, apenas um (ressuscitação cardiopulmonar) apresenta correspondência direta com os diagnósticos e procedimentos disponíveis no SIH/SUS. Muitos critérios recomendados pela OMS necessitam de informações detalhadas, como resultados de exames laboratoriais, parâmetros clínicos e duração de sintomas e/ou intervenções, que não estão disponíveis no SIH/SUS. Para contornar essas limitações, os autores utilizam critérios aproximados, que muitas vezes não refletem uma disfunção orgânica, como pretendido pela definição da OMS. Como resultado, os valores encontrados nesses estudos de incidência de near miss materno utilizando o SIH/SUS 4,5 são três a quatro vezes superiores aos relatados em estudos que realizam coleta de dados em prontuários 6,7.
Como alternativa para as dificuldades de operacionalização dos critérios da OMS, alguns autores adotam outras definições 8,9, como os critérios de Mantel e Waterstone, contrariando o propósito original da OMS ao recomendar uma definição padronizada de casos de near miss materno, que é permitir a comparação dos resultados entre diversos serviços e países.
Já a segunda proposta, de implantação da notificação de casos de near miss materno no SINAN, não parece ser de fácil operacionalização. Além da inexistência de código na Classificação Internacional de Doenças (CID) para casos de near miss materno, já mencionada pelos autores 1, estima-se que 1% das gestantes seja caso de near miss materno, o que, no Brasil, representaria cerca de 20 mil casos por ano. Entretanto, para a identificação de casos de near miss materno, é preciso que sejam triados os casos de morbidade materna grave, para que entre eles sejam identificados os que atendem aos critérios de disfunção orgânica. Casos de morbidade materna grave são mais frequentes, estimados em 10% do total de gestações. Ou seja, seria necessário criar uma estrutura de vigilância dos cerca de 2 milhões de nascimentos para identificação de 200 mil casos de morbidade materna grave e posterior notificação dos casos de near miss materno. Portanto, embora possível, a notificação do caso de near miss materno exigiria uma estrutura complexa de vigilância das internações obstétricas.
Sem desmerecer as propostas apresentadas pelos autores, e reforçando a necessidade de implantação de um sistema de vigilância da morbidade materna grave, e não apenas do near miss materno, apresentamos duas alternativas. A primeira é a utilização do SIH/SUS para a vigilância da morbidade materna grave, utilizando a definição da OMS para as “condições potencialmente ameaçadoras à vida (CPAV)” 2. Para a classificação desses casos, a OMS propõe 26 critérios baseados em diagnósticos e procedimentos, a maioria deles com operacionalização direta no SIH/SUS. Apenas quatro critérios não podem ser utilizados, seja por falta de código CID e procedimentos correspondentes no SIH/SUS (placenta acreta, increta ou percreta; retorno à sala cirúrgica; intubação não anestésica) ou ausência de informações específicas (trombocitopenia < 100.000).
Em recente edital de ciência de dados em saúde da mulher, com financiamento do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) e da Fundação Bill & Melinda Gates (Estados Unidos), foi efetuado o cálculo do indicador de morbidade materna grave para todo o Brasil, por município, para o período de 2012 a 2020, utilizando os critérios da OMS para as CPAV. Além da frequência desses casos, são apresentadas as principais causas de morbidade (hipertensão, hemorragia e infecção) e quatro indicadores de manejo (transfusão de hemoderivados, realização de procedimentos cirúrgicos, internação em unidade de terapia intensiva (UTI) e tempo de permanência maior do que sete dias). Os indicadores calculados são de acesso gratuito e estão disponíveis na página de Internet do Observatório Obstétrico Brasileiro (https://observatorioobstetrico.shinyapps.io/painel-vigilancia-saude-materna/). Esses dados já permitem a análise e monitoramento de morbidade materna grave em todo o país, sendo de grande relevância, principalmente para os cerca de 4 mil municípios brasileiros que não apresentam óbitos maternos regularmente.
A segunda alternativa seria a implantação de um Sistema de Informação Perinatal (SIP), a exemplo do sistema adotado pela Organização Pan-Americana da Saúde (OPAS) e já implementado em diversos países da América Latina. O SIP permitiria o monitoramento dos casos de near miss materno e morbidade materna grave 10, bem como de outros indicadores relacionados à assistência perinatal. Uma outra possibilidade seria a implantação de uma Autorização de Internação Hospitalar específica para as internações obstétricas (AIH obstétrica), integrada ao SIH/SUS já existente, o que permitiria a identificação correta de todas as internações obstétricas, assim como o monitoramento e a avaliação das práticas assistenciais e dos desfechos maternos e perinatais, incluindo casos de morbidade materna grave e near miss materno. A implantação de fichas específicas nos prontuários hospitalares, visando à identificação de casos de morbidade materna grave e near miss materno, facilitaria o registro de casos, já utilizada com sucesso em outros contextos 11.
A ampliação da vigilância da saúde materna, visando à redução da mortalidade materna, é uma necessidade no país. Esperamos que o debate iniciado por Ferreira et al. 1 contribua para a definição da melhor estratégia a ser adotada e sua efetiva implementação.
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- 1Ferreira MES, Coutinho RZ, Queiroz BL. Morbimortalidade materna no Brasil e a urgência de um sistema nacional de vigilância do near miss materno. Cad Saúde Pública 2023; 39:e00013923.
- 2World Health Organization. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. https://apps.who.int/iris/bitstream/handle/10665/44692/9789241502221_eng.pdf (acessado em 11/Jul/2023).
» https://apps.who.int/iris/bitstream/handle/10665/44692/9789241502221_eng.pdf - 3Departamento de Informática do SUS. Tabnet. https://datasus.saude.gov.br/informacoes-de-saude-tabnet/ (acessado em 11/Jun/2023).
» https://datasus.saude.gov.br/informacoes-de-saude-tabnet/ - 4
Iron Maiden – The Wicker Man
The Wicker Man
Iron Maiden
Hand of fate is moving and the finger points to you
He knocks you to your feet and so what are you gonna do
Your tongue has frozen now you’ve got something to say
The piper at the gates of dawn is calling you his way
You watch the world exploding every single night
Dancing in the sun a new born in the light
Say goodbye to gravity and say goodbye to death
Hello to eternity and live for every breath
Your time will come
Your time will come
Your time will come
Your time will come
The ferryman wants his money you ain’t gonna give it back
He can push his own boat as you set off up the track
Nothing you can contemplate will ever be the same
Every second is a new spark, sets the universe aflame
You watch the world exploding every single night
Dancing in the sun a new born in the light
Brothers and their fathers joining hands to make a chain
The shadow of The Wicker Man is rising up again
Your time will come
Your time will come
Iron Maiden – Rime Of The Ancient Mariner
Rime Of The Ancient Mariner
Iron Maiden
Hear the rime of the ancient mariner
See his eyes as he stops one of three
Mesmerizes of one of the wedding guests
Stay here and listen to the nightmares of the sea!
And the music plays on, as the bride passes by
Caught by his spell, and the mariner tells his tale
Driven south to the land of the snow and ice
To a place where nobody’s been
Through the snow fog flies on the albatross
Hailed in God’s name, hoping good luck it brings
And the ship sails on, back to the north
Through the fog and ice and the albatross follows on
The mariner kills the bird of good omen
His shipmates cry against what he’s done
But when the fog clears, they justify him
And make themselves a part of the crime
Sailing on and on and north across the sea
Sailing on and on and north ‘til all is calm
The albatross begins with its vengeance
A terrible curse, a thirst has begun
His shipmates blame bad luck on the mariner
About his neck, the dead bird is hung
And the curse goes on and on and on at sea
And the thirst goes on and on for them and me
Day after day, day after day
We stuck nor breath nor motion
As idle as a painted ship upon a painted ocean
Water, water, everywhere, and all the boards did shrink
Water, water, everywhere, not any drop to drink!
There!, calls the mariner
There comes a ship over the line
But how can she sail with no
Wind in her sails and no tide?
See, onward she comes
Onward she nears, out of the sun
See, she has no crew
She has no life; wait, but there’s two!
Death, and she life in death
They throw their dice for the crew
She wins the mariner
And he belongs to her now
Then, crew one by one
They drop down dead, two hundred men
She, she, life in death
She lets him live, her chosen one
One after one, by the star dogged moon
Too quick for groan or sigh
Each turned his face, with a ghastly pang
And cursed me with his eye
Four times fifty living men
And I heard nor sigh nor groan
With heavy thump, a lifeless lump
They dropped down, one by one
The curse, it lives on in their eyes
The mariner, he wished he’d die
Along with the sea creatures
But they lived on, so did he
And by the light of the moon
He prays for their beauty, not doom
With heart he blesses them
God’s creatures, all of them too
Then, the spell starts to break
The albatross falls from his neck
Sinks down like lead, into the sea
Then down in falls, comes the rain!
Hear the groans of the long dead seamen
See them stir and they start to rise
Bodies lifted by good spirits
None of them speak, and they’re lifeless in their eyes
And revenge is still sought, penance starts again
Cast into a trance and the nightmare carries on
Now the curse is finally lifted
And the mariner sights his home
Spirits go from the long dead bodies
Form their own light and the mariner’s left alone
And then a boat came sailing towards him
It was a joy, he could not believe
The pilots boat, his son and the hermit
Penance of life will fall onto him
And the ship, it sinks, like lead, into the sea
And the hermit shrieves the mariner of his sins
The mariner’s bound to tell of his story
To tell his tale wherever he goes
To teach God’s word by his own example
That we must love all things that God made
And the wedding guest’s a sad and wiser man
And the tale goes on and on and on
Iron Maiden – Flight Of Icarus
Flight Of Icarus
Iron Maiden
As the Sun breaks, above the ground
An old man stands on the hill
As the ground warms, to the first rays of light
A birdsong shatters the still
His eyes are ablazed
See the madman in his gaze
Fly, on your way, like an eagle
Fly as high as the Sun
On your way, like an eagle
Fly, touch the Sun, yeah
Now the crowd breaks and a young boy appears
Looks the old man in the eye
As he spreads his wings and shouts at the crowd
In the name of God, my father, I’ll fly
His eyes seem so glazed
As he flies on the wings of a dream
Now he knows his father betrayed
Now his wings turn to ashes, to ashes, his grave
Fly, on your way, like an eagle
Fly as high as the Sun
On your way, like an eagle
Fly, touch the Sun
Yeah
Fly, on your way, like an eagle
Fly as high as the Sun
On your way, like an eagle
Fly as high as the Sun
On your way, like an eagle
Fly, touch the Sun
On your way, like an eagle
Fly
Fly as high as the Sun
Oh
Iron Maiden – Blood Brothers
Blood Brothers
Iron Maiden
If you’re taking a walk through the garden of life
What do you think you’d expect you would see?
Just like a mirror reflecting the moves of your life
And in the river reflections of me
Just for a second a glimpse of my father I see
And in a movement he beckons to me
And in a moment the memories are all that remain
And all the wounds are reopen again
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
And as you look all around at the world in dismay
What do you see? Do you think we have learned?
Not if you’re taking a look at the war-torn affray
Out in the streets, where the babies are burnt
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
There are times when I feel I’m afraid for the world
There are times I’m ashamed of us all
When you’re floating on all the emotion you feel
And reflecting the good and the bad
Will we ever know what the answer to life really is?
Can you really tell me what life is?
Maybe all the things that you know that are precious to you
Could be swept away by fate’s own hand
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
When you think that we’ve used all our chances
And the chance to make everything right
Keep on making the same old mistakes
Makes untipping the balance so easy
When we’re living our lives on the edge
Say a prayer on the book of the dead
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
We’re blood brothers
And if you’re taking a walk through the garden of life
Iron Maiden – The Evil That Men Do
The Evil That Men Do
Iron Maiden
Love is a razor
And I walked the line on that silver blade
Slept in the dust with his daughter
Her eyes red with the slaughter of innocence
And I will pray for her
I will call her name out loud
I would bleed for her
If I could only see her now
Living on the razor’s edge
Balancing on the ledge
Living on the razor’s edge
Balancing on the ledge
Balancing on the ledge
Living on the razor’s edge
Balancing on the ledge
You know, you know!
The evil that men do lives on and on
The evil that men do lives on and on!
The evil that men do lives on and on
The evil that men do lives on and on!
Circle of fire my baptism of joy
And an end it seems
The seventh lamb slain
The book of life opens before me
And I will pray for you
Some day I may return
Don’t you cry for me
Beyond is where I learn
Living on the razor’s edge
Balancing on the ledge
Living on the razor’s edge
You know, you know!
The evil that men do lives on and on
The evil that men do lives on and on!
The evil that men do lives on and on
The evil that men do lives on and on!
Yeah, yeah!
Living on the razor’s edge
Balancing on the ledge
Living on the razor’s edge
You know, you know!
The evil that men do lives on and on
The evil that men do lives on and on!
The evil that men do lives on and on
The evil that men do lives on and on!
The evil
The evil
The evil that men do!
The evil
The evil
The evil that men do!
Yeah, yeah!
Iron Maiden – The Writing On The Wall
The Writing On The Wall
Iron Maiden
Across a painted desert lies a train of vagabonds
All that’s left of what we were, it’s what we have become
Once our empires glorious but now the empire’s gone
The dead gave us the time to live and now our time is done
Now we are victorious, we’ve become our slaves
A land of hope and glory, building graveyards for the brave
Have you seen the writing on the wall?
Have you seen that writing?
Can you see the riders on the storm?
Can you see them riding?
Can you see them riding?
Holding on to fury is that all we ever know
Ignorance our judge and jury all we’ve got to show
From Hollywood to Babylon
Holy war to kingdom come
On a trail of dust and ashes
When the burning sky is done
A tide of change is coming and that is what you fear
The earthquake is a coming, but you don’t want to hear
You’re just too blind to see
Have you seen the writing on the wall?
Have you seen that writing?
Can you see the riders on the storm?
Can you see them riding?
Can you see them riding?
Riding next to you
Have you seen the writing on the wall?
Have you seen that writing?
Can you see the riders on the storm?
Can you see the riding?
Have you seen the writing on the wall?
Have you seen that writing?
Can you see the riders on the storm?
Can you see them riding?
Can you see them riding?
Riding next to you
Iron Maiden – Dance Of Death
Dance Of Death
Iron Maiden
Let me tell you a story to chill the bones
About a thing that I saw
One night wandering in the Everglades
I’d one drink, but no more
I was rambling, enjoying the bright moonlight
Gazing up at the stars
Not aware of a presence so near to me
Watching my every move
Feeling scared and I fell to my knees
As something rushed me from the trees
Took me to an unholy place
And that is where I fell from grace
Then they summoned me over to join in with them
To the dance of the dead
Into the circle of fire, I followed them
Into the middle I was led
As if time had stopped still
I was numb with fear, but still
I wanted to go
And the blaze of the fire did no hurt upon me
As I walked onto the coals
And I felt I was in a trance
And my spirit was lifted from me
And if only someone had the chance
To witness what happened to me
And I danced, and I pranced
And I sang with them
All had death in their eyes
Lifeless figures
They were undead, all of them
They had ascended from hell
As I danced with the dead
My free spirit was laughing
And howling down at me
Below my undead body
Just danced the circle of dead
Until the time came to reunite us both
My spirit came back down to me
I didn’t know if I was alive or dead
As the others all joined in with me
By luck then a skirmish started
And took the attention away from me
When they took their gaze from me
Was the moment that I fled
I ran like hell, faster than the wind
But behind I did not glance
One thing that I did not dare
Was to look just straight ahead
When you know that your time has come around
You know you’ll be prepared for it
Say your last goodbyes to everyone
Have a drink and say a prayer for it
When you’re lying in your sleep
When you’re lying in your bed
And you wake from your dreams
To go dancing with the dead
When you’re lying in your sleep
When you’re lying in your bed
And you wake from your dreams
To go dancing with the dead
To this day I guess I’ll never know
Just why they let me go
But I’ll never go dancing no more
Till I dance with the dead
Iron Maiden – The Trooper
The Trooper
Iron Maiden
You’ll take my life, but I’ll take yours too
You’ll fire your musket, but I’ll run you through
So when you’re waiting for the next attack
You’d better stand, there’s no turning back
The bugle sounds and the charge begins
But on this battlefield no one wins
The smell of acrid smoke and horses breath
As I plunge on into certain death
Oh!
Oh!
The horse he sweats, with fear, we break to run
The mighty roar of the Russian guns
And as we race towards the human wall
The screams of pain as my comrades fall
We hurdle bodies that lay on the ground
And the Russians fire another round
We get so near yet so far away
We won’t live to fight another day
Oh!
Oh!
We get so close, near enough to fight
When a Russian gets me in his sights
He pulls the trigger, and I feel the blow
A burst of rounds take my horse below
And as I lay there gazing at the sky
My body’s numb and my throat is dry
And as I lay forgotten and alone
Without a tear I draw my parting groan
Oh!
Oh!
Iron Maiden – Fear Of The Dark
Fear Of The Dark
Iron Maiden
I am a man who walks alone
And when I’m walking a dark road
At night or strolling through the park
When the light begins to change
I sometimes feel a little strange
A little anxious when it’s dark
Fear of the dark
Fear of the dark
I have a constant fear that something’s always near
Fear of the dark
Fear of the dark
I have a phobia that someone’s always there
Have you run your fingers down the wall
And have you felt your neck skin crawl
When you’re searching for the light?
Sometimes when you’re scared to take a look
At the corner of the room
You’ve sensed that something’s watching you
Fear of the dark
Fear of the dark
I have constant fear that something’s always near
Fear of the dark
Fear of the dark
I have a phobia that someone’s always there
Have you ever been alone at night
Thought you heard footsteps behind
And turned around and no-one’s there?
And as you quicken up your pace
You find it hard to look again
Because you’re sure there’s someone there
Fear of the dark
Fear of the dark
I have constant fear that something’s always near
Fear of the dark
Fear of the dark
I have a phobia that someone’s always there
Fear of the dark
Fear of the dark
Fear of the dark
Fear of the dark
Fear of the dark
Fear of the dark
Fear of the dark
Fear of the dark
Watching horror films the night before
Debating witches and folklore
The unknown troubles on your mind
Maybe your mind is playing tricks
You sense, and suddenly eyes fix
On dancing shadows from behind
Fear of the dark
Fear of the dark
I have constant fear that something’s always near
Fear of the dark
Fear of the dark
I have a phobia that someone’s always there
Fear of the dark
Fear of the dark
I have constant fear that something’s always near
Fear of the dark
Fear of the dark
I have a phobia that someone’s always there
When I’m walking a dark road
I am a man who walks alone