Though Brazil’s maternal mortality data for 2022 are still being gathered and analyzed, the numbers appear to show a trend toward prepandemic rates — rates that are considered to be quite high. Indeed, according to the Brazilian Obstetric Observatory (OOBr), there were 55.3 maternal deaths per 100,000 live births in 2019. The three main causes of these deaths were severe bleeding, high blood pressure, and hospital-acquired infections. So, what do the experts say must be done to tackle this situation? Improve specialized care for pregnant women, facilitate access to ICUs, and promote information campaigns.
“What we’re seeing is a return to the kind of maternal mortality rates that we had before COVID,” said Rossana Pulcineli Vieira Francisco, MD, PhD, a professor of obstetrics and gynecology at the University of São Paulo School of Medicine (FMUSP), São Paulo, Brazil, and one of the founders of the OOBr.
“Right now, based on preliminary data, the maternal mortality ratio (MMR) is 50.65 per 100,000 live births. But again, this is all very preliminary. What can be said is that things are trending back toward 2019 numbers. What we can’t say at this time is whether that trend will continue and get to that point.”
The committees verifying the data will have an additional 6 months to receive and evaluate case notifications. “Sometimes what happens is that a woman dies after giving birth, but the event isn’t reported as being a maternal death,” Francisco explained. Each case involving the death of a woman of reproductive age will be reviewed. A decision will then be made as to whether the death should be classified as a maternal death. If it is, then the notification will be revised to reflect that finding.
Using data from Brazil’s Ministry of Health, the global public health organization Vital Strategies produced a technical note about mortality during the COVID-19 pandemic. What was the extent of the MMR increases? Among White women, the MMR was 49.9 deaths per 100,000 live births in 2018; in 2021, that number was 118.6. Among Black women, the 2018 rate was 104 deaths per 100,000 live births; in 2021, it was 190.8. For those 2 years, the rate among Brown women went from 55.5 deaths to 96.5 deaths. Among Indigenous women, it increased from 99.9 to 149. In 2021, the total MMR was 112.9 deaths per 100,000 live births.
But even if Brazil’s 2022 numbers get to prepandemic maternal mortality levels, those levels are still very high. “The Ministry of Health has set a goal: to reduce the MMR to 30 deaths per 100,000 live births by 2030. We have 7 years in front of us, but the political will has to be there — to set this reduction as a goal and achieve it,” said Francisco. The year 2030 also features in the United Nations Sustainable Development Goals. The proposed target for child mortality is to end, by that year, preventable deaths of newborns and children under 5 years of age. All countries are aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 live births and under-5 mortality to at least as low as 25 deaths per 1000 live births.
Ongoing Initiatives
Successful strategies for reducing the MMR are underway in Brazil, but they are having only a local impact. One of them is the obstetric TeleICU (TeleUTI) program, which is coordinated by Francisco along with Carlos Carvalho, MD, PhD, director of the pulmonology division at FMUSP’s Heart Institute. The service remotely monitors and coordinates the care of women who have pregnancies that are considered high risk or women who are hospitalized in an ICU that is in the network of Brazilian Unified Health System institutions in 11 states.
In addition to offering in-person and virtual training, TeleUTI fosters daily clinical discussions with bedside physicians. The program started in 2021, at the height of the pandemic, and is funded by the Ministry of Health. In the first 6 months, the pioneering initiative reduced the MMR by almost 48%.
“There was a reduction from 267 deaths to 140 deaths per 100,000 live births,” Francisco reported. Today, hospitals that participate in TeleUTI have an MMR of 5%, similar to that found in developed countries. Francisco believes that it’s crucial that guidance be provided to healthcare professionals who treat pregnant and puerperal patients in the ICU. One reason is that there are changes in these women’s bodies. Because intensive care physicians may not be familiar with these changes, they need support. According to OOBr data, in 2018 and 2019, 64% of maternal deaths occurred in the puerperium. The next 2 years, that number was higher: 70% in 2020 and 74% in 2021.
Fortunately, the TeleUTI program will be expanded: Over the course of 2023, it will be brought to 16 more hospitals, for a total of 27 health centers, with a base institution in each region of the country. “When it comes to providing hospitals with all that’s necessary to treat high-risk pregnancies, both the Ministry of Health and the state governments need to be involved. This means setting up more ICU beds for these women and creating initiatives to encourage team members to become more proficient in the relevant care,” said Francisco. Noting that May 28 is the National Day for the Reduction of Maternal Mortality, she went on to say, “We can’t just be making these efforts on one day or during one month. Every day, every month, everywhere across the country, we need to be working to reduce the MMR.”
In addition, she noted, “We need to increase the prenatal care coverage that we have in Brazil and improve patient care. It should be clarified that we also need to have specialized sites where care can be provided in cases of high-risk pregnancy and have hospital units with the necessary equipment and testing facilities to care for these women — places that have not only an ICU where mom can be treated by obstetricians who specialize in high-risk pregnancies, but also a NICU where baby can be provided a high level of care.”
According to Francisco, another big weak spot in Brazil’s healthcare system has to do with transporting high-risk patients. “This service isn’t available at every hospital. So, we need to come up with a solution to ensure that a woman who needs treatment is able to get to a specialist unit promptly.”
Public Education
Francisco mentioned one other area where more attention could be given: communicating with the public. “We see news stories about reducing maternal mortality, but we don’t see, for example, awareness campaigns on TV. There are no measures aimed at educating people about the signs of postpartum infection, the signs of preeclampsia, and about what should be done to ensure that women showing these signs get the appropriate care.”
In Latin America and the Caribbean, nearly 8400 women die each year due to pregnancy-related complications. Inequities in socioeconomic status, gender, ethnicity, education, place of residence, and age increase the risk of dying during pregnancy, childbirth, and the puerperium. In March, the Regional Task Force for the Reduction of Maternal Mortality (GTR) launched the “Zero Maternal Deaths: Prevent the Preventable” campaign to address the dire situation.
The goal of this interagency initiative is to promote the implementation of policies and programs that will ensure that all women — no matter how much they earn, no matter where in the world they live — have equitable access to quality health services. Among the GTR members are the Pan American Health Organization/World Health Organization, United Nations Population Fund, United Nations Children’s Fund, US Agency for International Development, the Inter-American Development Bank, the World Bank, the International Confederation of Midwives, and the Latin American Federation of Obstetrics and Gynecology Societies.
This article was translated from Medscape’s Portuguese edition.
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