Maternal mortality is a largely preventable event (> 90%). It is directly associated with increasing poverty and starvation [12]. High maternal mortality ratios (MMRs) are mainly concentrated in countries with a peripheral economy, and these reveal severe violations of women’s rights to health.
Since mid-2020, publications on the deaths of pregnant and postpartum women in Brazil have alerted us to prepare and organize a complete healthcare network [13]. It focused on ensuring timely access and adequacy of clinical practices because of the specificities of Covid-19 in the pregnancy-puerperal cycle. Variables related to hospital care and social determinants of health were associated with increased odds of maternal mortality.
Social inequality plays a central role in explaining excess maternal deaths. Differences among pregnant women’s profiles in Brazil and other countries can be explained [14]. There is a high occurrence of comorbidities in the country whose etiology involves inflammatory processes, which are risk factors for complications from Covid-19, such as obesity, hypertension, diabetes and vasculopathy [15].
Conversely, these comorbidities were less associated with maternal deaths. These findings were previously described by Scheler et al. [16]. This study identified that comorbidity was associated with increased fatality rates for both groups but higher in the non-obstetric group (22.8% vs. 13.3%). We believe that the leading chronic conditions for which we identified decreased risks of maternal mortality, indicate different interventions in prenatal care. Pregnant women with these comorbidities tend to have better prior monitoring because of their high risks and may be more sensitive to changes with early intervention. Timely access to prenatal care thus is a strong determinant of controlling previous chronic conditions, which determines women’s prognosis.
Social determinants of health strongly influence these chronic conditions but are even more associated with access to health care. Social, economic and health policies would benefit from considering this contextual effect [17]. Therefore, racial, geographic and socioeconomic disparities require special attention [18]. Women with COVID-19 and deaths in the obstetric population had a heterogeneous geographical distribution. Municipalities with high socioeconomic dissimilarities showed higher MMRs than areas with better social and infrastructure indicators [18].
In low- and middle-income, as opposed to high-income countries, high birth rates and limited resources for healthcare contribute to increased risks of maternal death due to COVID-19 [19]. Brazil, however, has had a declining birth rate since the 1970s and poor quality prenatal and maternity care has a more powerful explanatory weight. Timely access to adequate maternity care is essential for women’s safety and quality of care [20]. Delay in receiving care is associated with adverse maternal outcomes. Thaddeus & Maine [21] developed the “Three Delays” model to assess access to maternity care, broken down into three phases: (1) delay in the decision to seek health care; (2) delay in identifying and reaching appropriate health facilities; and (3) delay in receiving appropriate care at the right time. This model is used today to explain severe maternal morbidities and deaths.
In Brazil, barriers to access maternity care with specialized, complex conditions and inadequate monitoring of obstetric complications persist [22]. They occur despite the warning of the CDC that COVID-19 increases the risk of pregnant and postpartum women to develop more severe forms, requiring hospitalization, intensive care and mechanical ventilation [23]. The number of maternal deaths in 2020 was impressive, but the numbers were more than three times higher in 2021 [24].
The pandemic also aggravated the difficulties in accessing maternity care across the country. Excess maternal mortality may be directly or indirectly related to this increase. Similar results had already been pointed out previously on a sub-national scale in Brazil [25]. The assumption of maternal deaths because of COVID-19 and unequal access to health care is also corroborated by Obstetric Observatory BRAZIL - COVID-19, which analyzes nationwide public databases to provide an interactive scientific monitoring platform-based analysis, disseminating relevant information regarding maternal and child health in the country [26].
The situation in Brazil demonstrates the importance of national leadership in confronting a pandemic. It is even more important to recognize the need for long-term global care to improve local public health [27]. High MMRs suggest the failure of the Brazilian health system. A solution requires the international community’s involvement since it affects global development. This scenario does not repeat itself in other LMICs, prolonging the pandemic’s impact on all [28]. For this reason, analysis of excess maternal mortality is a call for action at this point in the pandemic.
Our analysis has limitations. Total mortality data represent data available at the time of the study. Data, however, can change due to updates over the next few months. The maternal death pattern, however, is already worrying in the current scenario. Another limitation concerns low testing in Brazil. It prevents us from precisely knowing the numbers of COVID-19-infected pregnant and postpartum women. This information does not compromise the estimated calculation we use, however. Mortality Odds Ratios are precise in these circumstances, where the population base is unknown. We assume deaths in the general population (in our case: the childbearing age female population) to estimate the odds of factors we considered to be related to maternal mortality. We also know there is some imbalance between the age group in which most women with pregnancies (between 20 and 29 years old) are concentrated and the group with the highest prevalence of comorbidities (40 to 49 years old). However, we performed our analyses disregarding pregnancies’ order and we believe this minimized potential selection bias.
The COVID-19 pandemic may represent a significant immediate obstacle to Brazil’s achievement of SDGs by 2030. Excess maternal mortality and the considerable increase in women with near-misses caused by COVID-19, directly or indirectly, have placed the country in a precarious situation. Vaccination against Covid-19 started in Brazil in January 2021. Thus, it had no implications for our analysis. On the contrary, our evidence reinforces the need for expanded immunization in this group, including maintaining the calendar as a priority in vaccine booster doses.
To sum up, weWe should mention that this study concerns the very beginning of the pandemic when pregnancy was not yet identified as a clear risk factor and only the wild-type variant of Sars-Cov-2 was endemic. As soon as 2021 mortality data are available for Brazil, it is important to extend the present analysis to the entire period. Moreover, it is necessary to combine non-pharmacological measures and vaccination. We need to strengthen maternal health care from access to antenatal care to regulating obstetric ICU beds. Antenatal consultations must be qualified, encouraging physical distance measures. We also need to screen pregnant women for respiratory symptoms, distribute good quality masks, adopt universal testing on admission to maternity hospitals with molecular tests (RT-PCR) and provide obstetric care in hospital units with access to ICU beds for women with moderate and severe disease.
