Preventable maternal deaths return after discharge from Covid – 02/28/2023 – Health

Three years after the start of the Covid-19 pandemic, a period in which maternal mortality rates in Brazil doubled, going back to levels recorded 25 years ago, pregnant and puerperal women are more protected against Sars-CoV-2. However, they died again from causes such as hypertension, bleeding and infections, considered preventable in 90% of cases.

The country already had many weaknesses in obstetric care, but, with the health crisis, they intensified. One of the most important indicators is the maternal mortality ratio (MMR), which computes deaths related to complications during pregnancy and up to 42 days after delivery (puerperium).

In 2021, the RMM pointed out that, for every 100,000 live births, there were 110 deaths of women, the same rate recorded in 1998.

Preliminary data from the Ministry of Health, compiled by OOBr (Brazilian Obstetric Observatory), show that the number is almost double that recorded in 2019, the period before the pandemic, when the ratio was 57.9 deaths. In 2020, the official rate was 71.9 deaths per 100,000 live births.

In absolute numbers, there were 1,964 deaths in 2020 and 2,941 deaths in 2021. Data for 2022 are not yet consolidated.

Just for comparison purposes, in the United States, there were 861 maternal deaths in 2020 and 1,178 in 2021, according to the CDC (Center for Disease Control and Prevention). Together, they represent less than half of Brazilian deaths during this period.

Brazil is a signatory to an agreement signed with the UN (United Nations) in 2015 to reduce, by 2030, the maternal mortality ratio to a maximum of 30 per 100,000 live births, that is, almost a quarter of the number registered in 2021.

2019 Ministry of Health report obtained by Sheet shows that there is a 95% chance that the country will not reach the target. The MMR projected by ministry technicians for 2030 is 55.6 deaths per 100,000 live births.

The report toured cities in the north of the country, a region with a mortality rate of 140.8 deaths per 100,000, the highest in the country, heard health professionals, managers and, mainly, families who lost pregnant women and found a series of problems in the network of maternal and child care that will be portrayed in reports throughout this month.

Roraima led the ranking of maternal mortality in 2021, with 281.7 deaths per 100,000 live births, a level similar to that of countries in sub-Saharan Africa, such as Mozambique. In developed countries, the rate is around 10 per 100,000.

The deaths of Thais Kauana Rodrigues Diniz, 21, and her baby, in Boa Vista (RR), exemplify some of the bottlenecks. The young woman lived in a mining region, was in her 19th week of pregnancy, but had not had any prenatal consultations. She arrived at the Nossa Senhora de Nazareth maternity ward on January 12 with abdominal pain and loss of amniotic fluid.

Maternity works improvised in tents of a field hospital. The original building has been under renovation since June 2021. There was a promise from Governor Antonio Denarium (PP) to deliver the works in January of this year, which did not happen.

On the tenth day of Thaís hospitalization, it was found that the fetus had died in the womb, according to her aunt, Alessandra Araújo. The baby’s death adds to another 27 registered at the maternity hospital from the beginning of this year until February 7. In 2022, there were 20 deaths.

“She spent two days suffering after receiving medication to induce labor. She didn’t want to eat anymore, her belly started to swell, she just moaned in pain. I asked for help, it was clear that she was getting worse, but they said that the swelling was accumulation of gases. The situation in there is chaotic”, says Alessandra.

Already in serious condition, Thaís was taken to the General Hospital of Roraima, the only SUS with an ICU in the capital. Tests revealed uterine rupture and generalized infection (septicemia). She underwent surgery, was intubated, and died two days later, on January 27.

Maternity denies that there was negligence in the care. Regarding the deaths of babies, the state government says that the causes are diverse, “with part of them being related to the lack of adequate prenatal care”. About the maternity ward, he says that the building renovation services are in the final phase.

While the classic causes of maternal death, such as the puerperal infection that killed Thais, continue unabated, the country is still investigating deaths from Covid in 2021, the year in which the disease alone was responsible for 52% of deaths of pregnant women and mothers (1,524 out of a total of 2,941).

Recent review of studies published in the journal BMJ Global Health shows that pregnant women with Covid have eight times more risk of death compared to uninfected pregnant women. Newborns also have a greater chance of complications in cases where the mother contracted Sars-CoV-2.

An analysis published in The Lancet Regional Health Americas, in 2022, identified at least three barriers that Brazilian pregnant and postpartum women faced during the pandemic.

The first was the difficulty in accessing diagnostic tests.

The second was to find vacancies in hospitals. There was an average delay of seven days between the onset of symptoms and hospitalization. Family members heard in the analysis report that the pregnant women went several times to the same hospital or to up to five different institutions before being hospitalized.

The third barrier was access to adequate intensive care after hospitalization. Between 2020 and 2021, 1 in 5 dead pregnant women did not get access to the ICU, and 1 in 3 who were in the ICU were not intubated, according to OOBr data.

For obstetrician Rossana Pulcineli Francisco, professor at USP and coordinator of the Brazilian Obstetric Observatory, this factor, associated with the lack of trained professionals for assistance, was what most contributed to the high mortality rate.

“If an intensivist treats a pregnant woman the same way as other people, the results will not be good. For all parameters [de oxigenação, por exemplo]you have to think about the mother and the baby, intensivists and obstetricians need to work together.”

From a physiological point of view, during pregnancy, women undergo many changes that can cause a greater inflammatory reaction to Covid. Therefore, right at the beginning of the pandemic, the American CDC warned of the serious risk that the infection posed to pregnant women, with guidelines on proper care.

The Brazilian Ministry of Health also published a booklet on the subject, but without a network that could closely monitor these women in primary care and refer them to hospitals with ICU beds and trained professionals to assist them, the document was of little use. .

Historically vulnerable regions suffered the most. “We already predicted a tragedy because we didn’t see a maternal-infant network, an adequate health system to assist these women in prenatal care and childbirth. Without a policy to guarantee access, they were wandering through maternity wards, through hospitals” , says nurse Brena Gama, a researcher at the Instituto Evandro Chagas, in Belém (PA).

For doctor Fátima Marinho, senior researcher at Vital Strategies, the high number of maternal deaths is a reflection of the denial of the pandemic and sexual and reproductive rights in the administration of Jair Bolsonaro. “The lack of national coordination with the states and municipalities left each one to himself. There was no joint work to protect pregnant and postpartum women, even though there was already an alert that they represented a higher risk group.”

Doctor Rafaela Pacheco, director of communication at SBMFC (Brazilian Society of Family and Community Medicine), also cites barriers to access to legal abortion and the Covid vaccine for pregnant and puerperal women. “There was criminal negligence against this population. We knew that, with this lack of assistance, mortality would pop up.”

In 2020, only 55% of hospitals that performed legal abortion continued to serve women, according to the Legal Abortion Map. Unsafe abortion is the fourth leading cause of maternal death. Regarding vaccination against Covid-19 in pregnant and postpartum women, the Ministry of Health even made immunization conditional on the presentation of a medical prescription, generating low adherence in this group.

According to an analysis by OOBr, pregnant and postpartum women hospitalized with Covid-19 who had previously been vaccinated had a lower risk of needing an ICU (23.5% against 37.4%), intubation (4.8% against 18.8%) and to die (3% against 14.1%) when compared to those not immunized.

Nésio Fernandes, current Secretary of Primary Care at the Ministry of Health, says that the denialist approach given to the pandemic by the Bolsonaro government has meant that risk communication during pregnancy and the puerperium has been underestimated.

According to him, the ministry is going to reactivate the maternal and child mortality committees in the states and create a network for surveillance and monitoring of care for pregnant and postpartum women, especially in regions with health care gaps.

The first step is to resume Rede Cegonha, a project created in 2011 to support and finance care actions for pregnant women and babies, which had been extinguished by the Bolsonaro government in 2022 and replaced by another one that was much criticized for having left aside an entire multidisciplinary network already consolidated .

The previous management of the Primary Care Secretariat denies the lack of public policies to curb maternal deaths. He says that there were transfers of resources to improve the structures of maternity hospitals, preparation of technical material on the impact of Covid and support in training professionals.

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