Increase in maternal deaths is marked by racial inequalities – 03/14/2023 – Health

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

Even with a public policy focused on maternal and child health for more than a decade, Brazil has failed to reduce racial and regional inequalities associated with maternal deaths, which were aggravated by the Covid-19 pandemic.

Preliminary data show that in 2019 and 2021, the MMR (maternal mortality ratio) increased in all groups, including among white women, who, historically, are less affected compared to black, brown and indigenous women.

Analysis by Vital Strategies, based on information systems from the Ministry of Health, reveals that, between 2018 and 2021, the MMR among white women increased from 49.9 to 118.6 deaths per 100,000 live births.

The hypothesis is that the increase is related to the collapse faced by hospitals, denial of preventive measures and initial resistance to vaccinating pregnant women.

In the same period, among black women, the MMR went from 104 to 190.8 deaths per 100,000, the highest among all groups. Among brown women, it went from 55.5 to 96.5, and among indigenous women, from 99 to 149.

“What we see in maternal death surveillance is the chronicle of an announced death. The pregnant woman is not at high risk, but she is very poor, she has little access to prenatal care. Often, in prenatal care, the doctor prioritizes the ultrasound and does not order a VDRL [exame que identifica a sífilis] or urine test”, says doctor Fátima Marinho, senior researcher at Vital Strategies.

Complications at the end of pregnancy, such as urinary infection, even in a low-risk pregnant woman, worsen the prognosis. “She looks for the hospital and the problem is not identified, she goes to another and another until it gets very complicated and is hospitalized urgently. If she doesn’t die, she’ll get closer. All cases tell the same story”, she says.

The high number of maternal deaths reflects inequalities in access to health. In 90% of cases, they are preventable causes. Therefore, it is considered one of the most serious violations of women’s human rights.

Brazil is a signatory to an international agreement to reduce deaths of pregnant and puerperal women by 2030 to a level of 30 deaths per 100,000 live births, but a 2019 report by the Ministry of Health shows that, depending on the current rate, there are 95 % probability that the country will fail to achieve this target.

A new Ieps bulletin (Institute of Studies for Health Policies) that analyzes the main causes of the increase in maternal mortality and the proposals for coping points out that racial disparities linked to deaths already begin in prenatal care.

In the first year of the pandemic, for example, the number of white pregnant women who received adequate prenatal care fell by 0.54%. Among black women, the drop was 1.44%. Inadequate prenatal care is considered when medical care begins only after the third month of pregnancy or when fewer than six consultations were performed during the entire pregnancy.

“There was a worsening in the maternal death indicator for all women, but for black women, the worsening was more intense. This difference in access to prenatal care between whites and blacks had been reducing, but with the pandemic everything got worse. It is urgent that there are policies to strengthen primary care and actions aimed at caring for black mothers and women”, says Rony Coelho, a researcher at Ieps.

According to him, racial inequalities also mark the different regions of Brazil and predate the pandemic. In 2014, for example, 52.9% of black pregnant women in the North of the country did not have adequate access to prenatal care, against 21.7% among white women in the Southeast.

Another survey carried out at UFBA (Federal University of Bahia) shows that skin color also interferes with the monitoring of pregnant teenagers. While 64% of white girls have adequate access to prenatal care, this rate drops to 50% among black girls and 30% among indigenous girls, according to preliminary data from the survey on teenage pregnancy and motherhood.

According to Agatha Eleone, public policy analyst and one of the authors of the Ieps document, although there has been a public policy since 2011 to support and finance care actions for pregnant women and babies (Rede Cegonha), this was not enough to resolve the high maternal mortality rates and nor regional disparities.

Last year, the Jair Bolsonaro (PL) administration extinguished the Cegonha Network and replaced it with another maternal and child care network (Rami). This, in turn, was already extinguished by the management of President Luiz Inácio Lula da Silva (PT) earlier this year and there was the resumption of Rede Cegonha.

At the end of 2022, there was a forecast cut of BRL 18 million in the 2023 budget for the implementation of maternal and child policies. But, according to the Ministry of Health, there is still no definition of how much the budget for the area will actually be this year.

One of the main obstetric complications that lead to maternal death is hypertension (pre-eclampsia and eclampsia), which has increased its participation in deaths. In 2014, the ratio was 25.2 per thousand births. In 2021, it rose to 33.3 (up 34%).

“The best solution to reduce these deaths is an investment in primary care, efficient prenatal care,” says Agatha Eleone.

Meeting goals for the six prenatal consultations is linked to part of the funding for primary care, within the Previne Brasil Program, but 35% of Brazilian municipalities did not reach this goal in 2022, according to data from Impulso Gov.

Boa Vista, in Roraima, was one of them. In the first two years of the pandemic, the city also had the highest lethality rate of pregnant and puerperal women hospitalized by Covid (47.7%) among Brazilian capitals, according to an analysis by OOBr (Observatório Obstetrico Brasileiro). Palmas, in Tocantins, appears in second place, with 31%, and Rio Branco, in Acre, has 29.4%. The average for the country as a whole was 9.4%.

“These pregnant women went through the emergency room and came straight to the ICU in a very critical condition. Were we prepared? No, we weren’t. The maternity doesn’t have an ICU and there were moments [no HGR, Hospital Geral de Roraima] of looking at the patients, seeing the overcrowding and saying: ‘where to put the next one’?, recalls Helinana Barros Machado Machado, an intensive care nurse at the HGR.

According to Gabrielle Almeida Rodrigues, technical manager of Boa Vista in the area of ​​women’s health, the high mortality in 2021 was related to Covid: of the 28 deaths recorded in the capital, 21 were due to complications from the infection.

“We only have one public maternity hospital in the state, and we don’t have any maternal ICUs. Today, it’s functioning precariously, in an improvised place. Besides not being an appropriate place, it has a big deficit of professionals. This is the problem. main obstacle.”

Roraima has 15 municipalities, but only Boa Vista has a maternity hospital and a single highly complex public hospital. All serious cases in the interior are referred to the capital, in addition to those of Venezuelan and indigenous pregnant women. The state led maternal deaths in the country in 2021, with 282 deaths per 100,000 live births, a level similar to that of African countries.

“The demand has been growing a lot with immigration. We increase the number of professionals, of exams, but it is never enough”, says Rodrigues. According to her, the municipality has created new basic health units, expanding the existing ones, in addition to hiring and investing in professional qualification.

At the 31st week of pregnancy, Venezuelan Genny, 22, an indigenous Warao, had her first prenatal consultation last month, at a UBS in Boa Vista. It is her third pregnancy, and the first in which she is monitored, thanks to a partnership between UBS and UNFPA (United Nations Population Fund). “I liked it”, she summarized when leaving the consultation and having heard the baby’s heartbeat.

In a statement, the Health Secretariat of Roraima said that the State has been registering a large increase in the demand for maternal and child care and that the main challenge of the Hospital Materno-Infantil Nossa Senhora de Nazareth has been to guarantee assistance to Venezuelan women, who arrive at the unit without prenatal follow-up and with a high-risk clinical condition.

In 2022, there were 7,272 general visits to Venezuelans, with 2,329 deliveries. In all, the maternity performs around 50,000 births per year.

The secretariat also says that the maternity works are nearing completion and that there are projects to build a unit in the western part of Boa Vista, the most populous part of the capital, in addition to expanding the Hospital Délio de Oliveira Tupinambá, in Pacaraima, in the border with Venezuela.

Secretary Nésio Fernandes, secretary of primary care at the Ministry of Health, says that the goal of reducing maternal deaths by 2030 is achievable as long as investments in the maternal and child network take place in a short period of time.

“All the diagnoses have already been made. Now it depends on a portfolio of structuring decisions that take investments to the health regions.

According to him, the conditions that lead to maternal deaths go far beyond actions that can be performed in primary care. “They require a hospital structure, with capillarity of obstetric beds, obstetric and neonatal ICUs throughout the country.”

Fernandes states that, in this first semester, the federal administration is developing a cycle of strategic and intersectoral planning, for the definition of allocation of financial resources.

But as this will happen in practice, the changes in Rede Cegonha and the amounts involved should only be announced in the second half, according to the secretary.