Background: In 2000, the eight Millennium Development Goals (MDGs) set targets for reducing child mortality\r\nand improving maternal health by 2015.\r\nObjective: To evaluate the results of a new education and referral system for antenatal/intrapartum care as a\r\nstrategy to reduce the rates of Cesarean sections (C-sections) and maternal/perinatal mortality.\r\nMethods: Design: Cross-sectional study. Setting: Department of Gynecology and Obstetrics, Botucatu Medical\r\nSchool, Sao Paulo State University/UNESP, Brazil. Population: 27,387 delivering women and 27,827 offspring. Data\r\ncollection: maternal and perinatal data between 1995 and 2006 at the major level III and level II hospitals in\r\nBotucatu, Brazil following initiation of a safe motherhood education and referral system. Main outcome measures:\r\nYearly rates of C-sections, maternal (/100,000 LB) and perinatal (/1000 births) mortality rates at both hospitals. Data\r\nanalysis: Simple linear regression models were adjusted to estimate the referral system�s annual effects on the total\r\nnumber of deliveries, C-section and perinatal mortality ratios in the two hospitals. The linear regression were\r\nassessed by residual analysis (Shapiro-Wilk test) and the influence of possible conflicting observations was\r\nevaluated by a diagnostic test (Leverage), with p < 0.05.\r\nResults: Over the time period evaluated, the overall C-section rate was 37.3%, there were 30 maternal deaths\r\n(maternal mortality ratio = 109.5/100,000 LB) and 660 perinatal deaths (perinatal mortality rate = 23.7/1000 births).\r\nThe C-section rate decreased from 46.5% to 23.4% at the level II hospital while remaining unchanged at the level\r\nIII hospital. The perinatal mortality rate decreased from 9.71 to 1.66/1000 births and from 60.8 to 39.6/1000 births at\r\nthe level II and level III hospital, respectively. Maternal mortality ratios were 16.3/100,000 LB and 185.1/100,000 LB at\r\nthe level II and level III hospitals. There was a shift from direct to indirect causes of maternal mortality.\r\nConclusions: This safe motherhood referral system was a good strategy in reducing perinatal mortality and direct\r\ncauses of maternal mortality and decreasing the overall rate of C-sections.
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