Obstetric teleUTI reduces maternal deaths by 47.6% in the SUS – 03/21/2023 – Health

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

From a telemedicine room at InCor (Instituto do Coração), in São Paulo, physicians Larissa Talharo, intensivist, and Danielle Albernaz, obstetrician, discuss the case of a pregnant woman hospitalized in the ICU of the Hospital Materno Infantil Francisco de Assis, in Cachoeiro de Assis. Itapemirim, in Espírito Santo, more than 800 km away.

At the hospital in Espírito Santo, there is the team of obstetrician Inara Dardengo, who passes on to colleagues all the clinical, laboratory and imaging data of patient Charline, 34. At the 29th week of pregnancy, she has pre-eclampsia, one of the main causes of maternal mortality.

Charline’s baby weighs 950 grams, and efforts are now being made to ensure that the pregnancy continues a little longer with the mother and baby safe. The doctors at InCor ask about the patient’s parameters in the last 24 hours, such as temperature, heart rate, blood pressure and saturation, suggest adjustments in medications and a new ultrasound to evaluate the baby.

“The service works with protocols, but not all the answers are in the books. This daily change, even on weekends, improves the prognosis of patients and gives more security to the professionals who are here at the end”, says Inara Darlengo.

The Francisco de Assis hospital is part of a network of SUS institutions, in 11 states, that participate in an obstetric teleUTI program, coordinated by InCor and funded by the Ministry of Health. In the first six months, the initiative reduced by almost half (47.6%) the maternal mortality ratio (MMR) in the ICUs of these institutions: from 267 deaths per 100,000 live births to 140.

From April 2022 until last month, 851 cases of pregnant women and mothers hospitalized in ICUs were discussed. Hypertension, which increases the risk of pre-eclampsia and eclampsia, accounts for 37% of the demands. Currently, the average lethality rate of pregnant women in these hospitals is 5%, compared to developed countries.

The program provides for virtual and face-to-face training, in addition to daily clinical discussions, lasting one hour, between professionals from InCor and those from partner hospitals. At both ends, there are obstetricians and intensivists working together on clinical procedures.

“First, it’s necessary to train the teams. If I just connect here with there and I’m just giving orders ‘do this, do that’, it doesn’t work, the results are not good”, says pulmonologist Carlos Carvalho, professor at USP, director from InCor’s pulmonology division and one of the teleUTI coordinators.

The idea for the program came at the height of the Covid pandemic, in 2021, when the country doubled the maternal mortality ratio, going back to levels of 25 years ago. At the time, InCor had a teleICU for adults that supported public hospitals in the management of critical patients, who began to ask for help to care for their pregnant and postpartum women.

The Hospital das Clínicas in São Paulo had already set up an exclusive ICU for this public, with intensivists and obstetricians working together. With this strategy, the maternal mortality rate dropped from 10% to 5%, while the country’s average was 23%, according to obstetrician Rossana Pulcineli Francisco, a professor at USP and also coordinator of the obstetric teleICU.

Through a partnership with the IDB (Inter-American Development Bank) and the ministry, the virtual service was initially offered to five states. In April 2022, a new agreement was signed with the Ministry of Health, which chose the 11 states that are currently in the program —Rondônia, Pernambuco, Goiás, Ceará, Mato Grosso do Sul, Espírito Santo, Paraíba, Amazonas, Piauí, Alagoas and Minas Gerais.

According to Carvalho, one of the biggest risk factors for high maternal mortality in the pandemic was the anticipation of childbirth. “C-sections were performed during an extensive inflammatory process and this meant that many women had serious complications after surgery.”

The hospitals underwent training on lower risk sedatives for pregnant women, the best way to intubate them and place them in the prone position (face down), and adjustments in mechanical ventilation. “With the uterus, up there, compressing the diaphragm, one cannot want to put in the same volume of air as a lung of a non-pregnant person.”

In Carvalho’s opinion, training and coordination failures contributed to the rise in maternal deaths from Covid. “The lack of a network structure, quick training, central guidance, created chaos. Each one did something. There was a lot of misinformation, doctors prescribing drugs for Covid without the slightest sense”, he recalls.

Even with the cooling of the pandemic, there are still problems in the care of pregnant and puerperal women who arrive at the ICUs, according to Rossana Francisco. “There are changes in the woman’s organism that the intensivists are not aware of. There is a certain desperation and you give birth to a pregnant woman who is unable to do so. The correct thing would be to first stabilize the mother and then deliver the baby.”

This explains, at least in part, why more women have died after giving birth than during pregnancy. In the two years prior to the pandemic, in 2018 and 2019, 64% of maternal deaths occurred in the puerperium. In 2000 and 2021, 70% and 74%, respectively, according to OOBr data.

“The greatest risk of thrombosis, for example, is in the puerperium, but there is still a certain fear of starting with anticoagulation soon after surgery [cesárea]. Hence the importance of intensivists and obstetricians working together. In the program, we saw initial resistance on both sides. But when they start to see a reduction in maternal deaths, that changes.”

The program’s contract with the Ministry of Health expires in April, but, according to Helvécio Miranda Magalhães Júnior, secretary of Specialized Care at the ministry, it will be renewed.

Good initiatives have also taken place in primary care to improve care for pregnant women. In adequate prenatal care, with tests and at least six consultations, it is possible to identify and intervene early in risk factors that can lead to maternal death.

Impulso Gov, a non-profit organization that works to promote the use of data and technology in public management, has been providing free support to municipalities in improving their processes, helping them, for example, to identify cases of pregnant women who are not properly monitored by the prenatal.

It sounds simple, but it’s not. In many municipalities, the manager of a health unit still needs to access each medical record, individually, to verify possible pending issues, making scale monitoring unfeasible.

With the use of digital tools, the health professional identifies which women are with late prenatal care and creates strategies with the family health team to reach them.

According to data from the federal program Previne Brasil, in 2022, 34% of Brazilian municipalities were unable to carry out six prenatal consultations for 45% of their pregnant women (programme goal). In the North region, the rate was almost double.

With four months of monitoring by Impulso, the municipality of Minaçu, in Goiás, reached all prenatal goals in the last four months of 2022. The leap was from 37% to 49% in consultations, from 53% to 65% in the indicator testing for HIV and syphilis and from 57% to 61%, in the oral health of pregnant women.

In Roraima, the state that leads in maternal deaths in the country, the UNFPA (United Nations Population Fund) has sexual and reproductive health teams in Boa Vista and Pacaraima working in prenatal care within the shelters of the Acolhida Operation, which deals with the arrival of Venezuelans in the country, and occupations of the city.

It also promotes courses for health professionals on obstetric emergencies and urgencies and, recently, donated a suit for the control and management of postpartum hemorrhages, and trained public health professionals in Boa Vista and Pacaraima to use it.

According to Igo Martini, spokesperson for UNFPA in Roraima, with this equipment, there is a greater chance of stabilizing the clinical picture when transporting pregnant women to a hospital. The only maternity hospital in Roraima is in the capital. “A woman with a hemorrhage leaving Pacaraima needs to travel about three hours to the mother’s hospital in Boa Vista.”

The fund has eight indigenous cultural facilitators, refugees and migrants from the Warao and E’ñepá ethnic groups, who help other indigenous women access health services. There are even booklets translated from Portuguese into Warao. “Many pregnant women do not speak Portuguese or Spanish and experience difficulties in prenatal care due to lack of linguistic and cultural understanding.”

At the UBS on Combu Island, in Belém (PA), it is the bond created between the family health team and the pregnant women that is responsible for the high adherence to prenatal care: 90% of the pregnant women on the island have all the consultations recommended at the unit , which can only be reached by boat. Of these, 60% are accompanied by their partners.

“They go through a multidisciplinary team with a nutritionist, a psychologist and a dentist. And 100% of them are followed up by community health agents. That makes all the difference”, says family doctor Yuji Ikuta, professor at the Federal University of Pará.