Deaths of pregnant women leave a trail of mourning and expose flaws – 07/03/2023 – Health

The Maternal Mortality Reporting Series is a partnership with the Pulitzer Center

Áurea Monteiro, 28, died at 3:45 pm on March 31, 2021 in the ICU of Santa Casa de Belém, in Pará. Five hours later, Dienne Santos, 38, died in a UPA (Emergency Care Unit) seven kilometers away. Both had complications from Covid-19 after childbirth, orphaned their babies and a trail of grief that persists in families.

In the capital of the neighboring state, in Boa Vista, Roraima, indigenous health nurse Gracione da Silva Santos, 44, still mourns the death of his wife Almiza Prado, 37, in June 2020, in the first year of the Covid pandemic. Today, he takes care of the youngest, Valentina, born with her mother intubated in the ICU, and four other children.

The stories expose failures in public and private health services at the height of the health crisis, help explain why Brazil doubled the maternal mortality rate in 2021, with the North region in the lead, and point out the priority areas that require improvement to contain deaths that can be avoided in 90% of situations.

Data from the federal government program Previne Brasil, extracted by Impulso Gov, a non-profit organization, show that, on average, 34% of Brazilian municipalities were unable to carry out six prenatal consultations for 45% of their pregnant women (target of the program ) in 2022. In the North region, this rate was almost double.

The problem was twice as bad: in December 2021, 6 out of 10 municipalities were in this situation. “Although the scenario has improved, we are talking about at least 1,800 cities that were unable to offer the recommended minimum of consultations”, says João Abreu, executive director of Impulso Gov.

Housewife Dienne Santos was one of the pregnant women who did not undergo prenatal care during the pandemic for fear of Covid, according to her mother-in-law Antonia Eremita Santos, 60, from Belém (PA). She started experiencing symptoms of the infection seven days after giving birth to Giovanni on March 14, 2021.

With a lot of coughing, she looked for a UPA in Belém, was medicated and released. That same night, with a high fever and shortness of breath, she returned to the health unit. With no vacancy in the ICU, she was admitted and soon after intubated right there. She died in the UPA after ten days, leaving her husband, the baby and two girls aged 6 and 9.

“She left here walking, talking. When would we imagine that she wouldn’t come back? That she would just leave there straight to the cemetery. At that time, nobody saw the body, nobody held a wake, nobody did anything”, says Antonia, thrilled.

According to the OOBr (Brazilian Obstetric Observatory), puerperal women hospitalized by Covid were 2.5% more likely to die from complications of the infection compared to pregnant women.

“In the puerperium [período até 42 dias após o parto], the woman has a greater risk for thrombosis, and Covid-19 also predisposes to thrombosis. The cesarean already leads to an inflammatory response and it can be potentiated by Covid-19”, explains obstetrician Rossana Pulcineli Francisco, professor at USP and coordinator of OOBr.

Another factor, adds the doctor, was the difficulty that pregnant and puerperal women had to access an ICU during the pandemic: 22% of them died away from intensive care and a third did not get to be intubated. “Saying that a woman died without having access to an ICU makes it clear that medical assistance failed to care for this woman.”

Pará recorded a mortality ratio of 117.6 deaths per 100,000 live births in 2021, above the Brazilian average of 110 deaths per 100,000.

According to Milena Ferreira Porfírio, coordinator of the child health area at the Municipal Health Secretariat of Belém, the increase in maternal mortality was related to the fact that several maternal and child actions were paralyzed, and efforts were directed towards confronting Covid.

But even with the cooling of the pandemic, there are still several barriers to be overcome, such as the lack of doctors and the turnover of professionals, which end up undermining the bond with patients and non-adherence to prenatal care.

Difficulties in accessing obstetric beds also persist and have been discussed with the state government, which is responsible for high-complexity hospital care. “There needs to be a link between primary care and the maternity hospital where the pregnant woman will have the baby to avoid traveling at the time of delivery, another cause that increases the risk of mortality for the mother or the baby”, says Porfírio.

In a note, the Secretary of Health of Pará attributes the rise in maternal deaths in the pandemic to the lack of structure in primary care, which led to the worsening of cases. He says that the state has reorganized and strengthened, in the 144 municipalities, the work process in the three levels of maternal and child care, from the prenatal program to medium and high complexity hospitals.

The folder also states that, as a result of these actions, Pará presented a 46% reduction in maternal mortality in 2022 compared to 2021.

Manager of a snack bar in Belém, Áurea Monteiro had health insurance and started prenatal care in the private network in the fifth month of pregnancy, when she found out she was pregnant. In early March 2021, she had flu-like symptoms and called the plan’s call center, which reassured her, advising her to stay at home.

At that time, the state of Pará had accumulated more than 9,000 deaths since the beginning of the pandemic and almost 383,000 cases. On the 13th of that month, Governor Helder Barbalho (MDB) announced a seven-day lockdown for the metropolitan region of Belém.

At home, Áurea got worse. He had a high fever, chills and a little shortness of breath. Worried, João Carlos, her husband, took her for a quick test at the pharmacy, which attested to Covid.

The woman was hospitalized and underwent an emergency cesarean section. The next day, she was taken to the ICU, intubated, and died a week later.

“They were desperate days. My brother just cried. We see the reports that Covid took father, mother, but it’s very difficult when it happens to someone close. We don’t accept it”, says sister-in-law Claudia Helena Azevedo Santos, 36, who breastfed her niece Elisa, 2, for two months.

João was approached by the report, but did not want to talk about the subject and did not allow photos of the woman to be published. “For me, this subject is still very complicated,” he said.

7.5 km away, Antonia regrets the absence of Dienne, the daughter-in-law she considered a daughter. “She was always joking, happy. She loved to bake the cakes I made. We were very close. How could she conform?”, She asks her.

After Dienne’s death, Carlos, her husband, moved to Santa Catarina with their children. “He suffered a lot, he even lost more than 20 kilos. I try to encourage him, I say he’s not the only one who lost his wife, but it’s not easy, I know.”

Carlos was approached by the report, but he also did not want to talk about it. He and his wife had been together for 14 years.

Almost three years after his wife’s death, nurse Gracione Santos, from Boa Vista (RR), says he still thinks about her every day as he takes care of the couple’s five children, aged between 3 and 17 years old. Nursing technician at the Nossa Senhora de Nazareth maternity hospital, Almiza had heart problems and was very afraid of being infected by the coronavirus.

After the diagnosis of Covid and with a drop in oxygen saturation, she was admitted and intubated in the maternity ward, the only one in the state that serves high-risk pregnancies, but which does not have an obstetric ICU. Currently, it also works in an improvised way, in canvas tents.

As her condition worsened, Almiza was transferred to the HGR (Hospital Geral de Roraima) and underwent an emergency cesarean section before completing six months of pregnancy. However, the hospital does not have a neonatal ICU and Valentina, weighing just over 1 kg and measuring 38 cm, was transferred to the maternity’s neonatal ICU.

HGR is the only general hospital in the state. In addition to serving the 15 municipalities, it assists patients from Venezuela and Guyana, countries that border Roraima. At the beginning of the Covid pandemic, the institution collapsed.

“Often we didn’t have vacancies to accommodate everyone, and we had a high mortality of pregnant women, a clientele that ended up being forgotten”, says infectologist Mario Asato, responsible for one of the ICUs at the HGR. He also had Covid in 2021, was intubated and was hospitalized for 28 days.

With his wife and newborn daughter in critical condition, Santos was divided between the two hospitals. “I would go to the maternity ward in the morning to cherish Valentina and in the afternoon to the HGR. Even though I couldn’t be with Almiza [intubada na UTI], stayed there. Even when she could, she said: ‘Love, don’t leave me alone'”, says the nurse.

At night, he devoted himself to his four children. “They went to my bed and we prayed for God to heal her. One night we asked that his will be done. The next day, I entered the ICU and told Almiza: ‘I love you and I will love you for the rest of my life , but if you have to go, you can go. I’ll be a good father to our children’.”

The woman died that night after 36 days in the ICU. Valentina left the maternity ward one month and 24 days after the birth, of which 54 days in the ICU.

Roraima led the ranking of maternal mortality in 2021, with 281.7 deaths per 100,000 live births, a level similar to that of African countries.

In a note, the Health Department of Roraima states that it has been recording a substantial increase in the demands for care in all health units, including Nossa Senhora de Nazareth.

According to the folder, a series of measures have been adopted to improve care at the maternity ward, such as training professionals, hiring servers and constant evaluation of indicators.

The secretariat also says that the main challenge in this unit is to ensure care for pregnant women from Venezuela. Many of them, continues the folder, arrive without prenatal care and with a high-risk clinical condition.

After the loss of his partner of 15 years, Santos tried to manage his own pain, the care of a premature newborn, the sadness of the other children, and the financial difficulties caused by the loss of income, which continue to this day.

The following year, in 2021, the woman’s grief was added to those of her mother and father. Both died from complications from Covid. “I was devastated, but I thought: ‘I had my mother. What about Valentina who didn’t even have the opportunity to live with her mother. What about the boys who had so little time with her?'”