Maternal mortality and the lack of women-centered care in Brazil during COVID-19: Preliminary findings of a qualitative study

Brazil has the highest rates of maternal mortality due to COVID-19, worldwide.^1,2 As of December 1, 2021, there were 1948 reported cases of maternal deaths caused by COVID-19.³ Of those, 1488 occurred in 2021, 223% more than in 2020.³ Epidemiological data in Brazil shows that 59% of pregnant or puerperal women who died in 2021 due to COVID-19 had no prior risk factors or comorbidities.^2,4 A meta-analysis study also suggests that the increase in adverse impacts is related to the inefficiency of health care systems and an inability to manage the pandemic.⁵ In Brazil, the vaccine only became readily available for pregnant women in July 2021, after a series of political and judicial controversies.^6,7 We argue that a public health emergency demands women-centered responses to reduce adverse impacts on reproductive health.

We interviewed the relatives of twenty-five pregnant or puerperal women who died due to COVID-19 to better understand their experiences seeking medical care. The interviews lasted an average of sixty minutes each. The women's ages ranged from 24 to 45 years old, in the majority between 30 and 39 (n = 20). All women died in the second and third trimester of pregnancy, or postpartum. Only 7 of 25 of the women had previous medical comorbidities, which were mostly pregnancy-related (Table 1). The qualitative-descriptive nature of the study and the reduced sample size precludes us from any comparison with the Brazilian general population, however, our findings identified three barriers that impede effective and women-centered health care responses in the country.

Table 1.

Women's Profile (n = 25).

Variables	N	Gestational age*
Year of death		2nd trimester	3rd trimester	Puerperium
2020	15	3	10	2
2021	10	1	9	0
Attempts to access care before hospitalization	2nd trimester	3rd trimester	Puerperium
One	6	1	4	1
Two	10	2	7	1
Three	3	0	3	0
Four	4	1	3	0
Five	1	0	1	0
Six	0	0	0	0
Seven	1	0	1	0
Health care system	2nd trimester	3rd trimester	Puerperium
Public	16	4	12	0
Private	7	0	7	0
Public and private	2	0	2	0
Neonatal condition
Stillbirth	5	4	1
Neonatal death	1		1
Newborn survival	19		17	2
Comorbidities		2nd trimester	3rd trimester	Puerperium
Yes	7	0	5	2
No	18	4	14	0
Age		2nd trimester	3rd trimester	Puerperium
24-29	3	1	2
30-39	20	3	15	2
40-42	2	0	2	0
Race		2nd trimester	3rd trimester	Puerperium
Black	13	2	9	2
White	11	2	9	0
No information	1	0	1	0
Children		2nd trimester	3rd trimester	Puerperium
No children	10	1	7	2
1 or more children	15	3	12	0
Country Region		2nd trimester	3rd trimester	Puerperium
North	3	1	2	0
Northeast	9	3	6	0
Midwest	2	0	2	0
Southeast	10	0	8	2
South	1	0	1	0

^⁎Gestational age at the time women started to seek medical care due to COVID-19.

First, there were delays in identifying the pregnant women's COVID-19-related symptoms and testing them. Relatives mentioned that women were discharged from the hospital after confirmations of fetal health, with only medicines to relieve mild symptoms. Women were told that their respiratory symptoms, such as dyspnea/shortness of breath, were “pregnancy sickness/fatigue”, “nervousness”, “something in their head”, and some were even asked whether they had “unlearned how to be a mother, unlearned how it is to be pregnant”, or were referred to a psychiatrist.

Second, there were delays in hospitalizing women after the diagnosis of COVID-19. Brazilian epidemiological data recorded an average of 7 days between the onset of symptoms and hospitalization for pregnant women with a confirmed diagnosis of COVID-19.² Health services were reluctant to admit pregnant women with severe acute respiratory symptoms. For those who managed to confirm a COVID-19 diagnosis, often on their own via private services even though Brazil has a public health care system, the refusal of care was justified by the fact that maternity wards were purportedly not prepared to admit patients with COVID-19. Almost all of the pregnant women went to the same facility multiple times or to up to five different facilities before being admitted. The refusal of care was even more evident for Black women; their relatives reported more frustrated attempts to access care before hospitalization and more aggressive practices of blaming women for the infection or for neglecting its symptoms.

Third, there were delays in providing intensive care after hospitalization, such as ICU admission, invasive ventilation, and early labor induction. The Brazilian Obstetric Observatory also paints a worrying picture, showing that one in every five pregnant and puerperal women who died due to COVID-19 did not have access to ICU care, and 32.4% were not intubated.² Proper intervention and invasive measures, such as intubation and preterm labor induction, were postponed awaiting fetal development. Physicians justified these delays as “the need to save both lives”. Studies also found a significant increase in the rate of stillbirths during the pandemic.⁵ Among the 25 women in our study, there were 6 stillbirths or neonatal deaths. In all cases where the fetus did not survive, the gestational age at the time of seeking care was lower than the average for the others: 21 weeks, in contrast to 32 weeks.

Our findings revealed failures in medical care that were compounded by racial discrimination and harmful gender norms. Almost all of the women who died faced the effects of poverty and the intersections of other inequities. The lack of women-centered obstetric care is a consequence of health care systems not prioritizing sexual and reproductive health during public health emergency responses. To mitigate the impacts of COVID-19 and other public health emergencies on women's lives, it is urgent to embrace new models of women-centered care, including applying an intersectional gender lens to preparedness for and response to health emergencies.

Contributors

All who have contributed substantially to the work have been acknowledged. D Diniz, L Brito, G Rondon, participated equally in all stages of preparation and revision of the manuscript. All authors have approved the submitted version of this manuscript.

Ethics statement

This study protocol was approved by the University of Brasilia Research Ethics Committee for Humanities and Social Sciences (CAAE: 35554220.4.0000.5540).

Data sharing statement

The datasets generated during and/or analyzed during the current study are not publicly available due to ethical protection accordingly to the International Ethical Guidelines for Health-related Research Involving Humans in order to guarantee autonomy, privacy and confidentially regarding sensitive matters investigated in this research. Although the data would be available from the corresponding author on reasonable request.

Declaration of interests

The authors declare that they have no competing interests.