Renata Moura

Journalist

Asheelley Vieira Santos was 17 years old when she saw her story turn into a nightmare, in São Paulo.

She was in her sixth month of pregnancy when she felt pain, lost the baby and, after being hospitalized to remove it, ended up dying in the hospital with supposed symptoms of Covid-19.

Cleide, Selidalva, Priscila, Marília, Aline, Viviane, Rafaela, Regivane, Saionara, Daiane, Joyce, Glaucia, Eliane and six other unidentified Brazilian women – including one in Rio Grande do Norte – would also have died while pregnant or days after childbirth in cases reported as suspected or confirmed of the disease in the media, in official sources or in hospital records. 

The tragic end of the women would have occurred between March and May of this year and was identified in a global survey that the Santos Dumont Institute (ISD) carried out for a month and released this Thursday (28), National Day to Reduce Maternal Mortality. ISD is a Social Organization of the federal government linked to the Ministry of Education and a reference in teaching, research, extension and assistance to the population – via the Unified Health System (SUS) – in the areas of maternal and child health, people with disabilities, in neurosciences and neuroengineering.

The survey on maternal mortality associated with Covid-19, the disease caused by the new coronavirus, is part of a series of publications by the Institute focused on the health of pregnant or postpartum women during the pandemic.

Click here to access illustrations and here to see information about it. Already infollowing graphic see data on mortality:

Mapped deaths

Due to the lack of official statistics during the survey period, maternal mortality stories were mapped by the Santos Dumont Institute mainly based on reports published on news portals and TVs in Brazil and abroad. In three cases, information released by official sources or hospitals was used that mentioned victims supposedly of Covid-19. The research covered texts and videos published in Portuguese, English and Spanish (click here to see the data).

Of the 39 cases found, 20 are in Brazil. The number exceeds that of 8 countries combined, including the United States and the United Kingdom, which until the publication of this report were leading in overall deaths caused by the disease, according to the World Health Organization.

“We currently have unprecedented visibility for the issue of maternal mortality in the country – a challenge that is still far from being overcome and which demands urgent strategies to guarantee safe motherhood”, analyzes Reginaldo Freitas Júnior, general director of ISD, doctor in science doctors from USP, professor in the Department of Tocogynecology at UFRN and National Instructor of the Zero Maternal Death from Postpartum Hemorrhage Strategy of the Pan American Health Organization/World Health Organization (PAHO/WHO).

He claims that the Ministry of Health's initial understanding that pregnant women were not among the population groups most vulnerable to the effects of the virus underestimated long-standing deficiencies in structure and care, which already left women at risk. Only in the week of April 13 were pregnant and postpartum women included by the government in the so-called “risk group” – requiring enhanced care.

See below the interview shown on 29/05, on InterTV, Globo affiliate, about the ISD survey regarding maternal mortality:

'Old weaknesses show their worst face in the pandemic'

“What it seems”, according to Freitas Júnior, “is that Covid-19 is bringing to light important weaknesses in the maternal health care network, which pre-existed, many of them chronically, but which in a situation like this pandemic show the your worst face.”

One example he cites is related to the lack of prenatal care at the end of pregnancy. “It’s a problem that we’ve been trying to combat for years, but it’s still real in many cities. The end of pregnancy is a period much more prone to complications, it is where there are many more risks to maternal health, but these pregnant women are no longer guaranteed weekly evaluation returns until the time of delivery”, he says. 

“It's as if prenatal care has ended and now all you have to do is go to the maternity ward if you feel pain or have signs of labor, when your water breaks, or if you experience bleeding, but it shouldn't work like that. The end of pregnancy is a period of great vulnerability and the pregnant woman needs to be guaranteed at least one weekly appointment until the baby is born, but this did not happen before and now due to the pandemic, even more so. This guarantee is not being fulfilled and many pregnant women are without this care, without this support, without the necessary surveillance at a time of greater risk.” 

'Pilgrimage to give birth'

Another point of weakness that he points out is the lack of linkage of many pregnant women to a maternity hospital or reference service for childbirth. In other words, many women have no guarantee of where they will give birth. “They receive prenatal care at SUS and this does not guarantee them the place, the maternity ward that will receive them at the time of birth. The pilgrimage to give birth is still a Brazilian reality, and it is still a northeastern reality. These women often travel great distances, and even more than one municipality, in search of a maternity ward, a hospital that guarantees assistance during childbirth.” 

The expert analyzes the situation as “a flagrant violation of rights that compromises the safety of pregnant women, puts the outcome of the pregnancy at risk and is undoubtedly a factor that increases the occurrence of maternal mortality”. The women cited in this report were at different stages of pregnancy or postpartum when they died. The news that focuses on their deaths does not detail whether problems like those mentioned by the expert were recorded. Family members of Asheelley and Glaucia, however, said in an interview with TVRecord and G1 that they did not receive the necessary medical assistance in the last days of their lives.

Asheelley's mother and the family of another woman, Priscila, also claim that they contracted Covid-19 in the hospital. The health departments of São Paulo and Rio de Janeiro denied errors in the cases.

Prenatal care: Women are deprived of services and more vulnerable

In the reorganization of health services due to the pandemic, many Brazilian cities understood that prenatal care and family planning services were not essential and could be suspended – and this brought “great losses and risks to women”, according to the director of ISD. They ended up, he says, deprived of support and more vulnerable at this time.

“In addition to harming women’s safety, it also risks, in addition to complications inherent to Covid-19, an increase in obstetric risk due to other complications, such as hypertension during pregnancy, lack of control of gestational diabetes, risk of premature birth and inadequate (and not timely) treatment of infections”, observes Freitas Júnior. “Prenatal care is essential and cannot stop, in the SUS and in the private network, even prenatal care for low-risk pregnancies. It has to be guaranteed to Brazilian pregnant women.” 

Deaths in the states

The cases of maternal mortality associated with Covid-19 mapped by the Santos Dumont Institute are distributed among 11 states, with the majority in Rio de Janeiro (20%) and São Paulo (20%). It is in the North and Northeast, however – regions that already had the highest overall maternal mortality rates in Brazil, according to the most recent official data – that are the worst-case scenarios in a comparison of mortality rates per 100,000 inhabitants. 

Amapá, Paraíba, Amazonas and Rio Grande do Norte record, respectively, the worst rates considering this parameter, according to the survey. Next are Espírito Santo, Pará, Rio de Janeiro, Maranhão, Pernambuco, São Paulo and Bahia.

Globally, the analysis shows that Brazil accounts for 51,28% of deaths of pregnant women or women who have recently given birth in the world, associated with suspected or confirmed Covid-19. 

The data suggests that the country not only has more victims than others combined, but also the highest rate of maternal deaths supposedly due to Covid-19, per 100,000 inhabitants. The number is 21.20% higher than that of the United Kingdom, for example, the second country in terms of deaths on this list, but, according to Freitas Júnior, recognized as a model in terms of a maternal care network and guarantees of women's rights. The distance between the two countries in this field can also be measured by latest Maternal Mortality Ratio (MMR) data released by the World Health Organization (WHO), a snapshot of maternal deaths per 100,000 live births. The British number is almost nine times lower than the Brazilian one.

• The subject was the subject of the report “Maternal mortality rate due to coronavirus is higher in Brazil than in 8 countries in the world combined”, published in the newspaper O Povo, from Ceará. Click here to read.

Direct and indirect factors cause almost 40 thousand victims 

Until the conclusion of the ISD survey, there are no official statistics on the causes of direct or indirect maternal deaths, such as Covid-19, this year in Brazil. A bulletin published this week by the Ministry of Health shows, however, that, “from 1996 to 2018, 38,919 maternal deaths were recorded in the country, of which approximately 671 TP3T were due to direct obstetric causes, that is, due to obstetric complications during pregnancy, childbirth or the puerperium due to interventions, omissions, incorrect treatment or to a chain of events resulting from any of these causes.” The main reasons identified are hypertension, hemorrhage, puerperal infection and abortion.

Indirect obstetric causes, according to the Ministry of Health, result from diseases pre-existing during pregnancy or that developed during this period, not caused by direct obstetric causes, but aggravated by the physiological effects of pregnancy. Examples of these causes include diseases of the circulatory system, respiratory diseases, AIDS and maternal infectious and parasitic diseases. According to the bulletin, between 1996 and 2018, indirect causes were responsible for 29% of maternal deaths. The others were classified as non-specific obstetric causes.

The document draws attention to the fact that, in 2009, the outbreak of influenza A (H1N1) contributed to the increase in deaths from indirect obstetric causes, but does not analyze the trend with Covid-19.

Asheelley, mentioned at the beginning of this report, was the youngest among the victims of the disease identified by ISD. The death certificate indicated coronavirus infection. But the family – on the TV channel where the death was reported – accused the hospital of negligence, alleging delays in care and that she was exposed to the dangers of Covid-19 in the hospital. The São Paulo State Health Department denied this, in the same report, and said that she received the necessary assistance.

*Text updated after publication to add information.