The implementation of a safe motherhood referral system for maternal and perinatal health care was shown to be associated with a decrease in C-section rate and PMR at the Level II hospital. It also decreased PMR at the Level III hospital and stabilized the C-section rate. The equalization of direct and indirect obstetric causes of maternal mortality was also a significant improvement.
The excessive use of C-sections is a serious problem in Brazil, where rates are usually above 40% . C-sections are known to be associated with a higher rate of maternal complications [9, 10]. They result in rehospitalization for wound complications and infection, and the average initial hospital cost for a C-section delivery is higher than for the average vaginal birth . The decrease in the C-section rate observed at the Level II hospital demonstrates that it is possible to reverse the rising C-section rates in developing countries and, thereby, reduce maternal morbidity .
Perinatal mortality is a sensitive indicator of the quality of obstetric and neonatal care . According to the World Health Organization (WHO) , 98% of perinatal deaths occur in developing countries. In Brazil, the few available studies on perinatal death report a rate two- to three-fold higher than that observed in developed countries [12–14]. Indirect obstetric causes of death are considered not preventable and are more frequent in developed countries . In Brazil, direct obstetric causes account for most maternal deaths; preeclampsia predominates, followed by obstetric hemorrhage and puerperal infection . The referral system assessed herein did not cause a reduction in the maternal mortality ratio. Nonetheless, the equalization of the direct and indirect obstetric causes of maternal mortality showed that obstetric care improved over the course of the study. To allow comparison of data during the period this fact was not described in Brazil .
This program is an effective two-level, parallel system whose focus was to improve maternal and perinatal outcomes, strengthen the healthcare system and removes the barriers between obstetric and perinatal care at Level II and Level III hospitals. This strategy could be considered for use in other regions as an intervention for improving the safety of pregnancy .
Although effective as an example to aid planning by individual governments and financial supporting agencies there are some possible limitations of this type of study. The major objection was that this is a cross-sectional study without a control group and without a baseline assessment. This allows us to conclude that there is an association between the intervention and improved outcomes. Another potential weaknesses in the study could be other effects that may have contributed to the improved outcomes over 12 years like changing economic conditions, better conditions in antenatal care and general medical care, greater access to care not ruled by the referral system. Instead of these limitations it is our aim to encourage other groups to develop similar programs.
Our results are in accordance to previous study that reorganization of health system was of great value to eliminate inequality in health assistance improving health outcomes and results in lower PMR . The political and administrative system and the organizational structure will strongly affect operations and, in turn, service outputs. Subsequently, this will have a direct effect on the health of women and newborns [19, 20]. The organizational structure of safe pregnancy services [19, 21] (including service infrastructure, sectorial integration, service delivery strategies and partners) and safe pregnancy practices (including management supervision, training, commodities acquisition/distribution, research and evaluation, and transport) are all included in our program. Thus, our referral program could be considered for use as an intervention for improving the safety of pregnancy.
Governments have a long history of announcing lofty and well-meaning pledges to make the world a healthier place. The dominant model for improving public health focuses almost exclusively on the supply side of the health equation by improving the quality of services, expanding coverage, and telling people why they should use the health service and where it is available . With our program, a two-pronged approach was used: on the supply side, the health infrastructure was upgraded, while demand was increased . There is an increasing consensus that stronger health systems are keys to improving health outcomes .
This program could be considered a Safe Motherhood Model (SMM) , i.e., a program to assist in effectively allocating the resources associated with reducing the maternal mortality ratio. The adequacy of delivery care, the access to services and the social and economic content have a direct influence on safe motherhood . National programs to improve maternal and neonatal health are wide ranging, and they involve very large investments. However, uniform, periodic measurements of the levels and types of effort being made are rare. This report uses a methodology that covers a twelve-year period by component and region, with attention to specific criteria .
Regionalization provided a framework for in uterus or postnatal transfer of high-risk mother-perinatal dyads to the level of care that offered them the best chance for survival .
In conclusion, our results demonstrate the importance of prioritizing the reorganization of referral systems and are in agreement with the conclusions of Ronsmans et al.  reductions in perinatal mortality will require strategies such as early detection and management of health problems during pregnancy. This strategy supports the hypothesis that a safe motherhood referral system for antenatal/intrapartum assistance is a tool to ensure mothers and their infants survive during these crucial periods.