Reduction of maternal mortality due to preeclampsia in Colombia-an interrupted time-series analysis
Introduction. Preeclampsia is the most important cause of maternal mortality in developing countries. A comprehensive prenatal care program including bio-psychosocial components was developed and introduced at a national level in Colombia. We report on the trends in maternal mortality rates and their related causes before and after implementation of this program.
Methods: General and specific maternal mortality rates were monitored for nine years (1998-2006). An interrupted time-series analysis was performed with monthly data on cases of maternal mortality that compared trends and changes in national mortality rates and the impact of these changes attributable to the introduction of a bio-psychosocial model. Multivariate analyses were performed to evaluate correlations between the interventions.
Results: Five years after (2002–2006) its introduction the general maternal mortality rate was significantly reduced to 23% (OR= 0.77, CI 95% 0.71-0.82).The implementation of BPSM also reduced the incidence of preeclampsia in 22% (OR= 0.78, CI 95% 0.67-0.88), as also the labor complications by hemorrhage in 25% (OR= 0.75, CI 95% 0.59-0.90) associated with the implementation of red code. The other causes of maternal mortality did not reveal significant changes. Biomedical, nutritional, psychosocial assessments, and other individual interventions in prenatal care were not correlated to maternal mortality (p= 0.112); however, together as a model we observed a significant association (p= 0.042).
Conclusions: General maternal mortality was reduced after the implementation of a comprehensive national prenatal care program. Is important the evaluation of this program in others populations.
- maternal mortality
- population study
- bio-psychosocial model.
Mounier-Vehier C, Equine O, Valat-Rigot AS, Devos P, Carré A. Hypertensive syndromes in pregnancy. Physiopathology, definition and fetomaternal complications. Presse Med. 1999; 28: 880–5.
Herrera JA. Nutritional factors and lateral rest reduce pregnancy-induced hypertension in positive roll-over test primigravidae. Int J Gynaecol Obstet. 1993; 41: 31–5.
Herrera JA, Salmerón B, Hurtado H. Prenatal biopsychosocial risk assessment and the low birthweight. Soc Sci Med. 1997; 44: 1107–14.
Herrera JA, Chaudhuri GC, López-Jaramillo P. Is infection a major risk to preeclampsia. Hypoth Med. 2001;57: 393–7.
Herrera JA, Arévalo-Herrera M, Herrera S. Prevention of preeclampsia by linoleic acid and calcium supplementation: A randomized controlled trial. Obstet Gynecol. 1998; 91: 585–90.
Herrera JA, Shahabuddin AK, Ersheng G, Wei Y, GarcIa RG, López-Jaramillo P. Calcium plus linoleic acid therapy for pregnancy-induced hypertension. Int J Gynaecol Obstet. 2005; 91: 221–7.
Herrera JA, Arévalo-Herrera M, Shahabuddin AKM, Ersheng G, Herrera S, García R, et al. Calcium and conjugated linoleic acid reduces pregnancy-induced hypertension and decreases intracellular calcium in lymphocytes. Am J Hypertens. 2006; 19: 381–7.
Herrera JA, López-Jaramillo P, Shahabuddin AKM, Faisal M, Ersheng G, Wei Y, et al. Efectos de la suplementación oral con calcio y ácido linoleico conjugado en primigravidas de alto riesgo. Colomb Med. 2004; 35: 31–7.
Box GEP, Jenkins GM. Time Series Analysis-Forecasting and Contro. 2nd edition. Holden-Day; San Francisco: 1976.
Mislanova C, Martsenyuk O, Huppertz B, Obolenskaya M. Placental markers of folate-related metabolism in preeclampsia. Reproduction. 2001; 142: 467–76.
Herrera JA, Parra B, Herrera E, Arce R, López- Jaramillo P, Contreras A. Periodontal disease severity is related to high levels of C-reactive protein in preeclampsia. J Hypertens. 2007; 25: 1459–64.
Herrera JA, Hurtado H, Cáceres D. Antepartum biopsychosocial risk and perinatal outcome. Fam Pract Res J. 1992; 12: 391–9.
Sierra- Laguado J, García RG, Celedón J, Arenas-Mantilla M, Pradilla LP, Camacho PA, et al. Determination of insulin resistance using the homeostatic model assessment (HOMA) and its relation with the risk of developing pregnancy-induced hypertension. Am J Hypertens. 2007; 20: 437–42.
Kanajama N. Trophoblast injury: new biological and pathologic concept in preeclampsia. Croat Med J. 2003; 44: 148–56.
Fekete K, Berti C, Cetin I, Hermoso M, Koletzko BV, T Decsi. Perinatal folate supply: relevance in health outcome parameters. Matern Child Nutr. 2010; 6: 23–38.
Redman C, Sacks G, Sargent I. Preeclampsia: an excessive maternal inflammatory response to pregnancy. Am J Obstet Gynecol. 1990; 180: 499–506.
Herrera JA, Alvarado JP, Martínez JE. The psychosocial environment and the cellular immunity in the pregnant patient. Stress Med. 1988; 4: 49–57.
Kupferminc MJ, Peaceman AM, Aderka D, Socol ML. Soluble tumor necrosis factor receptors and interleukin-6 levels in patients with severe preeclampsia. Obstet Gynecol. 1996; 88: 420–7.
Greer IA, Lyall F, Perera T, Browel F, Macara LM, Cog M. Increased concentrations of cytokines interleukin-6 and interleukin-1 receptor antagonist in plasma of women with preeclampsia: a mechanism for endothelial dysfunction? Obstet Gynecol. 1994; 84: 937–40.
Coussons-Read ME, Okun ML, Nettles CD. Psychosocial stress increases inflammatory marker and alter cytokine production across pregnancy. Brain Behav Immun. 2007; 21: 343–50.
García RG, Celedón J, Sierra-Laguado J, Alarcón MA, Luengas C, Silva F, et al. Raised C-reactive protein and impaired flow mediated vasodilation precede the development of preeclampsia. Am J Hypertens. 2007; 20: 98–103.
Takiuti NH, Kahhalle S, Zugaib M. Stress in pregnancy: a new Wistar rat model for human preeclampsia. Am J Obstet Gynecol. 2002; 186: 544–50.
Garcia-Gómez RG, López-Jaramillo P, Tomaz C. The role played by the autonomic nervous system in the relation between depression and cardiovascular disease. Rev Neurol. 2007; 44: 225–33.
Cardwell MS. Stress: pregnancy implications. Obstet Gynecol Surv. 2013; 68: 119–29.
Salvador-Moysén J, Martínez-López Y, M R-AJ, Aguilar-Durán M, Terrones-González A. Genesis of preeclampsia: an epidemiological approach. ISRN Obstet Gynecol. 2012; 916914.
Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease. Circulation. 1999; 99: 2192–2217.
Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEARTH study): case-control study. Lancet. 2004; 364: 953–62.
Goldenberg RL, McClure M, Macguirre ER, Kamath BD, Jobe AH. Lessons for low-income regions following the reduction in hypertension-related maternal mortality in high-income countries. Int J Gynaecol Obstet. 2011; 113: 91–5.
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