Social determinants of COVID-19-related maternal deaths in Brazil].

Initially, COVID-19 infection was not associated with worse outcomes for pregnant and postpartum women. However, it soon became clear that the risk existed for the Brazilian obstetric population, especially for women with associated health conditions or social vulnerability factors [1].

In The Lancet Regional Health – Americas, Siqueira et al [2] performed a spatial analysis of all cases and deaths due to COVID-19 in the Brazilian obstetric population. The authors found a wide variation in the number of cases and maternal deaths per municipality, with worse outcomes in locations with lower health resources and higher socioeconomic inequalities, especially in the countryside. According to the study, COVID-19-related maternal deaths in Brazil reached 1,396 cases in June 2021, above the numbers documented elsewhere.

Brazilian maternal death ratio ranged from 52 to 60 per 100,000 live births between 2010 and 2018 [3]. During the period, considering the lowest and the highest death incidence per year (respectively, 1,691 in 2012 and 1,923 in 2014), the number of COVID-19-related maternal deaths in 15 months presented by Siqueira et al corresponded to an estimated increase of 75% in the overall maternal mortality [2,3].

Historically, most maternal deaths in the country are preventable, resulting from delays in adequate care [4]. Siqueira´s findings may be partly explained assuming that existent delays were aggravated during the pandemic, culminating in further barriers to health access, as well as poor quality of out- and in-hospital care. In this context, the first delay, "delayed decision to seek care by individuals and/or their family" may reflect hampered health access because of reduced public transport availability, lower family income, travelling quarantine restrictions, abnormal functioning of health units, and fear of contagion. The second delay, “delayed arrival at a healthcare facility that can provide adequate care” may reveal obstacles in referring patients due to the distance from home location to referral hospitals [1], limited health access within municipalities without Family Health Strategy [1], as well as overcrowded referral hospitals, as pointed out by Siqueira et al. The third delay, “delay in the provision of the necessary care and the necessary time at the institution of reference”, may also be explained by overcrowded hospitals and ICUs [5], in addition to the exhaustion and burden of work on health professionals [6].

The heterogeneity on distribution of cases and deaths due to COVID-19 in the Brazilian obstetric population in Siqueira´s analysis may relate to the limited availability of referral hospitals for pregnant women with coronavirus infection. Case notification has been typically carried out after the woman was transferred to a referral location, probably contributing to worse clinical outcomes in the process. Study limitations should be considered, mostly on account of the Influenza Epidemiological Surveillance Information System database, such as information input inconsistencies, outdated population data, and case analysis based on notification of severe acute respiratory syndrome (SARS) only. Nevertheless, the findings are alarming.

Structural obstacles in obstetric care preceded the COVID-19 pandemic in Brazil. For instance, only 15% of public maternity hospitals have ICUs [7], therefore trained obstetricians are scarce amidst intensive care staff. According to the authors, with the advance of the pandemic, several municipalities increased health services capacity by building temporary health units for screening and follow-up of people with like-flu symptoms, as well as by providing extra ICUs beds [2]. However, it did not necessarily imply in better outcomes, as the overall mortality rate in patients with COVID-19 in ICUs in Brazil is above the worldwide average [8].

The calamity of COVID-19-related-maternal deaths in Brazil depicted an ongoing crisis. The Brazilian Unified Health System (in Portuguese: SUS) was established in 1988 for universalization and democratization of health care [9]. However, underfunding and lack of priority investments are chronic issues [9]. The 2014 economic and political crisis deepened the situation, especially after 2016 parliamentary coup and Bolsonaro´s election in 2018. A Constitutional Amendment stablished drastic health funding reduction until 2036 [10].

Maternal mortality by COVID-19 suggest that Brazilian´s health system is failing from case identification to clinical management at different levels of care. Despite the disquieting number of deaths in the obstetric population, COVID-19 immunization for pregnant and postpartum women started only in July 2021, when more than a thousand of them had already died.

The 1,396 lost lives to COVID-19 during pregnancy and childbirth described by Siqueira et al portray a devastating scenario, with long-term consequences for Brazilian families and communities, not to mention the possible sequelae among the surviving women. Strategies to broaden quality obstetric care, especially in the most remote regions of the country, should be the goal of public policies for this population. Additionally, the beginning of COVID-19 vaccination for pregnant and postpartum women may help changing such indicators, albeit late.

Declaration of Competing Interest

The authors declare no conflicts of interest.