In 2006, CSP published a systematic review on maternal near miss ¹1. Souza JP, Cecatti JG, Parpinelli MA, Sousa MH, Serruya SJ. Revisão sistemática sobre morbidade materna near miss. Cad Saúde Pública 2006; 22:255-64.. International literature had already been discussing this event, but in Brazil, scientific production was still in its first steps. Now, in 2023, CSP revisits this topic in an article ²2. Ferreira 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. and an exchange of letters to the editors ³3. Domingues RMSM, Dias MAB, Saraceni V, Pinheiro RS, Paiva NS, Coeli CM. Vigilância da morbidade materna no Brasil: contribuições para o debate. Cad Saúde Pública 2023; 39:e00151123.^,44. Ferreira MES, Coutinho RZ, Queiroz BL. Resposta à Carta às Editoras de Domingues et al. Cad Saúde Pública 2023; 39:e00165123..

The relevance of studying the entire continuum of events in the pregnancy-puerperium cycle and their different levels of severity - from uncomplicated pregnancies to maternal death - is unquestionable ⁵5. Say L, Souza JP, Pattinson R; WHO Working Group on Maternal Mortality and Morbidity Classifications. Maternal near miss: towards a standard tool for monitoring the quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23:287-96.. In 2011, the World Health Organization (WHO) solidified concepts of maternal morbidity and proposed specific approaches ⁶6. World Health Organization. Evaluating the quality of care for severe pregnancy complications: the who near-miss approach for maternal health. Geneva: World Health Organization; 2011.. Other systematic reviews - national and international - have been published and knowledge has expanded ⁷7. Silva JMP, Fonseca SC, Dias MAB, Izzo AS, Teixeira GP, Belfort PP. Conceitos, prevalência e características da morbidade materna grave, near miss, no Brasil: revisão sistemática. Rev Bras Saúde Mater Infant 2018; 18:7-35.^,88. Hernández-Vásquez A, Bendezu-Quispe G, Comandé D, Gonzales-Carillo O. Worldwide original research production on maternal near-miss: a 10-year bibliometric study. Rev Bras Ginecol Obstet 2020; 42:614-20.^,99. England N, Madill J, Metcalfe A, Magee L, Cooper S, Salmon C, et al. Monitoring maternal near miss/severe maternal morbidity: a systematic review of global practices. PLoS One 2020; 15:e0233697.. Journals in the field of obstetrics and public health have been the major sources of scientific production on the topic.

However, beyond the advances in research, how are health services monitoring severe maternal morbidity and maternal near miss?

The article by Ferreira et al. ²2. Ferreira 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. brings a concrete proposal to make maternal near miss surveillance mandatory in Brazil. These authors suggest a model based on the Brazilian Information System for Notificable Diseases (SINAN) or the use of data from the Hospital Information System of the Brazilian National Unified Health System (SIH/SUS). Two letters to the editors in response to the article discuss the strengths and the weaknesses of the proposal and bring new contributions to monitoring, extending it to severe maternal morbidity ³3. Domingues RMSM, Dias MAB, Saraceni V, Pinheiro RS, Paiva NS, Coeli CM. Vigilância da morbidade materna no Brasil: contribuições para o debate. Cad Saúde Pública 2023; 39:e00151123.^,44. Ferreira MES, Coutinho RZ, Queiroz BL. Resposta à Carta às Editoras de Domingues et al. Cad Saúde Pública 2023; 39:e00165123.. The adoption of a system similar to the Latin American Perinatal Information System (SIP; http://www.sipplus.org/), linked to the Latin American Center for Perinatology, Women and Reproductive Health (CLAP/SMR; https://www.paho.org/en/clap), is perhaps the most appropriate proposal for the Brazilian reality, considering the national expertise in information systems ¹⁰10. Coelho Neto GC, Chioro A. Afinal, quantos Sistemas de Informação em Saúde de base nacional existem no Brasil? Cad Saúde Pública 2021; 37:e00182119., the specificities of obstetric events, and the possibilities of joint analysis of data from countries in the region ¹¹11. Sosa C, de Mucio B, Colomar M, Mainero L, Costa ML, Guida JP, et al. The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System. BMC Pregnancy Childbirth 2023; 23:605.^,1212. Serruya SJ, de Mucio B, Martinez G, Mainero L, de Francisco A, Say L, et al. Exploring the concept of degrees of maternal morbidity as a tool for surveillance of maternal health in Latin American and Caribbean settings. Biomed Res Int 2017; 2017:8271042.^,1313. Aleman A, Colomar M, Colistro V, Tomaso G, Sosa C, Serruya S, et al. Predicting severe maternal outcomes in a network of sentinel sites in Latin-American countries. Int J Gynaecol Obstet 2023; 160:939-46.. Some Brazilian institutions have already established surveillance and research partnerships using SIP ¹⁴14. Serruya SJ, Gómez Ponce de León R, Bahamondes MV, De Mucio B, Costa ML, Durán P, et al. EviSIP: using evidence to change practice through mentorship - an innovative experience for reproductive health in the Latin American and Caribbean regions. Glob Health Action 2020; 13:1811482.^,1515. Gomez Ponce de Leon R, Baccaro LF, Rubio Schweizer G, Bahamondes V, Messina A, de Francisco LA, et al. Building a network of sentinel centres for the care of women in an abortion situation: advances in Latin America and the Caribbean. BMJ Glob Health 2022; 7:e010059.. The system could initially be implemented as a sentinel surveillance in other maternity hospitals across the country, until it is incorporated universally.

However, other questions become necessary in this debate. The first concerns the assignment of monitoring tasks. Maternal death surveillance, which is mandatory in Brazil and has been regulated since 2008, provided for hospital committees at municipal, state, and federal level ¹⁶16. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Manual dos comitês de mortalidade materna. Brasília: Editora do Ministério da Saúde; 2009.. Are these committees responsible for the surveillance of severe maternal morbidity and maternal near miss? Currently, few studies address the work of the committees, but undoubtedly they have made important contributions, where they are properly implemented, improving information ¹⁷17. Carvalho PI, Vidal AS, Figueirôa BQ, Vanderlei LCM, Oliveira CM, Pereira CCB, et al. Comitê de mortalidade materna e a vigilância do óbito em Recife no aprimoramento das informações: avaliação ex-ante e ex-post. Rev Bras Saúde Mater Infant 2023; 23:e20220254.. But do we have enough committees? And will the committees be able to handle this additional task?

The second question is a consequence of the first. Within the composition of the committees and/or health units, which professionals will complete the surveillance forms necessary for any monitoring system? Are our health professionals well acquainted to the topic? Are the topics of severe maternal morbidity and maternal near miss covered in Medicine, Nursing, and Obstetrics courses?

Generally, the teaching of maternal mortality, information systems, and epidemiological surveillance is included in subjects in the area of public health. But this does not seem to be enough, given the many problems of underreporting and inadequate completion, even for the most serious event, which is maternal death ¹⁸18. Ribeiro CM, Costa AJ, Cascão AM, Cavalcanti ML, Kale PL. Strategy for the selection and investigation of deaths of women of reproductive age. Rev Bras Epidemiol 2012; 15:725-36.^,1919. Estima NM, Alves SV. Maternal deaths and deaths of women of childbearing age in the indigenous population, Pernambuco, Brazil, 2006-2012. Epidemiol Serv Saúde 2019; 28:e2018003.^,2020. Feitosa-Assis AI, Santana VS. Occupation and maternal mortality in Brazil. Rev Saúde Pública 2020; 54:64..

Strengthening the committees quantitatively and qualitatively seems to be the answer, whatever the choice for monitoring severe maternal morbidity and maternal near miss. Including the topic in health curricula and training professionals in how to complete surveillance forms and death certificates can be another step towards qualifying the fight against severe maternal morbidity and maternal near miss.

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