Maternal Mortality: A Matter of Public Health Policies

Maternal mortality is a worldwide problem and concern, continuing to be a public health problem, the ratio of the same has been decreasing but still to those recommended by the World Health Organization. Objective: To perform a literature review, highlighting current aspects of maternal mortality. Method: The research was carried out in electronic databases Lilacs, Bi reme-BVS, Scielo and BDENF, limited to the last 23 years. Those addressed pre-defined aspects of interest to the study proposal were selected —materna l mortality, public health policies, and the new approaches to the problem. Results: Maternal death is directly related to the living conditions of the population, showing variability from country to country (developed and developing), but its decrease is inherent to public policies and political will.

• Mortality
• Maternal
• Policies
• Publish
• Health

1. Introduction

Maternal mortality should be a reality for all women, so what we are recording is not, however, it continues to be a serious public health problem and a violation of human rights [1] [2] .

Considered a public health challenge, maternal mortality is responsible for 99% of maternal deaths in developing countries [3] .

In the year 2000, world leaders got together and decided to establish a global agenda of minimum commitments for the promotion of human dignity. Thus, eight Millennium Development Goals (MDGs) were listed to be achieved by 2015. Among these, the fifth goal stands out, which aimed to improve maternal health, with two global goals: to reduce maternal mortality by three-quarters the level observed in 1990, and universalize access to sexual and reproductive health [4] .

The care given to women before, during and after pregnancy results in the reduction of neonatal, child and maternal morbidity and mortality, thus demonstrating the quality of life of a society and government, in order to guarantee a society ready for the challenges of the globe and with a sustainable future [5] . For this to happen, it is necessary to understand the psychological, social and biological transformations that are registered at these times, in order to adapt the ideal and adequate assistance for each woman [5] .

The World Health Organization (WHO) defines maternal death as the death of a woman while pregnant or within a period of 42 days after the termination of pregnancy, regardless of the duration or location of the pregnancy (topical or ectopic), due to any cause related to or aggravated by the pregnancy. This can be classified as direct maternal mortality when related to pregnancy, childbirth or the puerperium and indirect when due to other causes, but the woman is pregnant [6] .

At the present time, approximately 830 women die every day in the world due to preventable complications related to pregnancy, childbirth or postpartum. From around 1990 to 2015, the global maternal mortality rate reduced only 2.3% per year, in some countries, the annual reduction was greater than 5% [7] .

In Brazil, data from the Ministry of Health reveal that, although at the expense of government policies, maternal mortality is reducing, it is still high, being around 50%, from 2000 to 2015 [8] .

In the Federative Republic of Brazil, the Mortality Information System (SIM) recorded 38,919 maternal deaths between 1996 and 2018; of these, 67% resulted from direct obstetric causes and 29% from indirect causes [9] .

In Portugal, the maternal mortality ratio in 2018 was 19.5 per 100,000 live births [10] .

More than fifty percent of maternal deaths in the world occur in Sub-Saharan Africa (SSA), where progress is almost imperceptible [11] .

In Africa, the main direct causes of maternal death are clandestine abortion, anaemia, eclampsia, haemorrhage, obstructed labor and puerperal infections. The main indirect causes are HIV/AIDS, malaria, viral hepatitis, pulmonary tuberculosis, infectious diarrheal diseases (cholera, typhoid fever and amoebiasis), tetanus, heart disease and sickle cell anemia [12] [13] .

There have been records of improvements and gains in maternal health on the African continent; maternal mortality has been reduced by nearly half the levels seen in the 1990s, and several African countries are making steady progress in their health policies toward achieving the millennium development goals. The average Maternal Mortality Ratio (MMR) in Africa has reduced from 990 per 100,000 women in 1990 to 460 per 100,000 by the end of 2013. The average percentage reduction in the MMR from the 1990 baseline was 44.8% [14] [15] .

The United Nations (UN) established the maternal mortality rate at 30 deaths per 100,000 LBs by 2030 [16] .

The availability of any maternal death would be avoidable if greater attention was paid to the early identification of risk factors and if obstetric care was adequate. Reproductive planning (contraception and conception), follow-up, early diagnosis and effective treatment of maternal complications that may arise during pregnancy, qualitative care during childbirth and postpartum tend to reduce deaths, enabling the fundamental right of being human, which is the right to life [17] [18] . Maternal mortality is an avoidable tragedy in 92% of cases because it occurs mainly in developing countries [19] .

In Angola, the maternal mortality ratio is considered high, similar to the African rate. This situation is due to the deficit of access to health services in general, limited coverage by health networks focusing on maternal and child care, and lack of qualified professionals. The high mortality around childbirth is all preventable, such as: hemorrhages, infections, and hypertensive disorders, if these women had access to qualified professional assistance during pregnancy, childbirth and postpartum, to determine an opportune window of intervention and care adjusted to each mother [20] .

According to research carried out by Maria (2021), in Angola, the mortality rate associated with pregnancy is 239 deaths per 100,000 live births (confidence interval from 164 to 313) [11] .

The objective of this work was to review the literature, descriptions of maternal mortality and public policies, to present what is new in the literature, in order to contribute to the reduction of the same.

2. Material and Methods

This study was carried out based on a literature review, using techniques that summarize the results of this research on the subject (maternal mortality), according to Gil (2008) [21] . selective reading, with exploratory reading consisting of a reading of the bibliographic material of interest to the research and which aims to verify to what extent the consulted work is of interest to the theme, then a selective reading is carried out, which consists of selecting the material that in fact interest in research.

The research was carried out through the search for scientific articles on the internet, using keywords, maternal mortality, policies, and public. Articles were searched in the following indexed databases: Virtual Health Library (BVS-BIREME), Latin American and Caribbean Literature in Health Sciences (LILACS), Nursing Database (BDENF) and Scientific Electronic Library Online (SCIELO).

Articles in Portuguese, Spanish and English, from the last 23 (twenty-three) years (period from 2000 to 2023), only in full were searched. Articles that were not freely available and those that did not have abstracts available for analysis in the databases were excluded (Figure 1).

In the four databases, 3475 scientific articles were initially found.

3. Presentation and Discussion of Results

The search was carried out using keywords. 33 complete articles were selected.

Most maternal deaths are preventable, which is why world leaders in solidarity with the cause have come together in order to lower the world maternal death rate [3] [4] to almost all deaths because they are 99% preventable through the implementation of public health policies worthy of human beings, analyzing the level and quality of care provided to the obstetric population, starting by knowing the causes of maternal death and intervening in the determinants of health [22] .

The world maternal mortality rate has reduced by 2.3% a year, even to those who need and quality of maternal life, preservation of human rights, qualitative assistance, taking into account the planning of termination of pregnancy as a therapeutic option whenever the patient is Hemo dynamically unstable, therefore, reinforcing policies in the health sector is an entity to always take into account, because the reductions in rates or reason for maternal mortality have been at the expense of implementing dignified public health policies, acceptable techniques, qualification of health professionals [9] [13] [14] [15] [16] [23] .

Research carried out around the world demonstrates that the most prevalent cause of maternal mortality is hemorrhage, results similar to those found by Medeiros et al. (2018), being an avoidable cause, thus demonstrating violation of human rights, being a cause of maternal death direct [3] [24] [25] .

The political will to implement public health policies has caused maternal deaths to decrease, the United Nations (UN) established the maternal mortality rate at 30 deaths per 100,000 LBs by 2030 [16] , the developing countries that have the highest maternal mortality rates, are making an effort to improve these indicators, the African continent has lowered the rates even so much remains to be done to meet this United Nations target, today with the implementation of new, more up-to-date health policies, the reduction in the cradle continent was reduced by half when compared to the 90s [14] [15] [16] .

The average Maternal Mortality Ratio (MMR) in Africa has reduced from 990 per 100,000 women in 1990 to 460 per 100,000 by the end of 2013, this is due to current health policies, where they focus on comprehensive care for the health of women, health professionals increasingly involved with the duty of protecting life, guaranteeing women’s rights, guaranteeing free access to health services and medicines during prenatal care, delivery and postpartum, results found in research carried out by Rhaman et al. (2014) and Lima et al. (2016) [26] [27] .

One of the gains in reducing maternal mortality has to do with better intervention policies in indirect deaths, where one of them is the control of HIV infection and concomitant vertical transmission of the virus, research carried out in South Africa by (Chola et al., 2015), demonstrate these results, having impacted on the continental evaluation [28] .

There is a great need to encourage undergraduate and graduate courses and permanent education in health services to improve the performance of professionals, in order to provide increasingly high-quality care. In addition, multidisciplinary and interdisciplinary teamwork in networks is another fundamental element for providing qualified care in maternal and child care 27. It is also necessary to expand and use effective resources, such as adequate monitoring of labor and delivery, the use of the partogram, and above all, in labor and delivery, such as: use of oxytocin, amniotomies, Kristller maneuvers, routine episiotomy, etc., offering technological resources, from the simplest to the most complex, available and qualified human resources, these elements contribute to a favorable maternal outcome [29] .

When there is weakness in the resources mentioned above, at different levels of care, they are often responsible for maternal mortality, hence the imperative of investment in public policies in order to lower and improve this indicator that translates the development of a nation [30] [31] .

For these reasons, the use of specific protocols for the identification of obstetric complications, together with the training of professionals, investments in technologies, was an effective measure in reducing maternal mortality in Africa and Brazil [29] [31] [32] [33] [34] .

There are still several challenges to improving women’s reproductive health. Challenges range from family planning, greater coverage of routine reproductive health care and more advanced obstetric care, and reporting of maternal deaths. We have a long investigative and assistance path because it lacks the social and political commitment of all those involved, who directly or indirectly have the responsibility for preventing maternal mortality [24] .

Evaluating the clinical and epidemiological profile of maternal deaths is of great importance, as it is important for a critical analysis of the assistance offered to women, which will allow us to create policies adjusted to this population [9] [35] [36] .

4. Conclusions

Due to the above, the causes of maternal deaths continue to be mainly caused by direct causes. The deficit of health units, qualified personnel, availability of resources and policies aimed at this population continues to be a major public health problem, especially in developing countries.

Since direct obstetric deaths are the majority, this result shows the need to adapt procedures for managing pregnancy, childbirth and the puerperium.

The causes of death continue to be mostly preventable causes.

Strategies used to prevent maternal mortality do not require very advanced technological resources, but rather simple and low-cost measures with an impact on the life of the obstetric population.

There is a need to analyze the difficulties in implementing programs and public policies that involve women in the reproductive period, but adjust them to each region and level of complexity of care.

Improvements are needed in maternal-fetal care in the pregnancy-puerperal cycle.

In view of the results, there is a presence of socioeconomic vulnerability and some weaknesses in public policies, thus highlighting the need for work that seeks to improve primary care for pregnant women, as well as effective social control with expansion and qualification of Maternal Death Committees and the mobilization of managers for more funding, health professionals and civil society in the promotion of public policies that seek to reduce global maternal mortality, particularly in developing countries.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References

1. Freitas-Júnior, R.A.O. (2020) Avoidable Maternal Mortality as Social Injustice. Revista Brasileira de Saúde Materno Infantil, 20, 607-614. https://doi.org/10.1590/1806-93042020000200016

2. Shah, J.S., Revere, F.L. and Toy, E.C. (2018) Improving Rates of Early Entry Prenatal Care in an Underserved Population. Maternal and Child Health Journal, 22, 1738-1742. https://doi.org/10.1007/s10995-018-2569-z

3. Blencowe, H., Cousens, S., Jassir, F.B., Say, L., Chou, D., Mathers, C., et al. (2016) National, Regional, and Worldwide Estimates of Stillbirth Rates in 2015, with Trends from 2000: A Systematic Analysis. The Lancet Global Health, 4, e98-e108. https://doi.org/10.1016/S2214-109X(15)00275-2

4. Organization United Nations (ONU) (2014) The Millennium Development Goals Report 2014. United Nations, New York.

5. Gadson, A., Akpovi, E. and Mehta, P.K. (2017) Exploring the Social Determinants of Racial/Ethnic Disparities in Prenatal Care Utilization and Maternal Outcome. Seminars in Perinatology, 41, 308-317. https://doi.org/10.1053/j.semperi.2017.04.008

6. Alves, M.M., Alves, S.V., Antunes, M.B. and Santos, D.L. (2013) Causas externas e mortalidade materna: Proposta de classificação. Revista de Saúde Pública, 47, 283-291. https://doi.org/10.1590/S0034-8910.2013047003642

7. Barreto, B.L. (2021) Perfil epidemiológico da mortalidade materna no Brasil no período de 2015 a 2019. Revista Enfermagem Contemporanea, 10, 127-133. https://doi.org/10.17267/2317-3378rec.v10i1.3709

8. Brasil, Ministério da Saúde, Secretaria de Vigilancia em Saúde (2018) Saúde Brasil 2017: Uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Ministério da Saúde, Secretaria de Vigilancia em Saúde, Departamento de Vigilancia de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Ministério da Saúde, Brasília.

9. Ribeiro, C.A. and Freire, C.H. (2022) Mortalidade materna: Perfil clínico e epidemiológico de uma maternidade pública do Amazonas. Femina, 50, 230-235.

10. Clode N. ,et al. (2020)Still the 2018 Maternal Mortality Rate in Portugal Ainda a propósito da taxa de mortalidade materna de 2018 Acta Obstétrica e Ginecológica Portuguesa 14, 9-10.

11. Maria, T.N. (2021) Cuidados Prénatais e Sua Influência Nos Resultados da Gravidez e do Parto, Luanda-angola. Ph.D. Thesis, Universidade do Porto (Portugal), Porto, 28.

12. Organização Mundial de Saúde Sede Regional Africana (2000) Promoting the Role of Traditional Medicine in Health Care Systems: A Strategy for the African Region. AFR/RC50/9. https://www.afro.who.int/sites/default/files/sessions/working_documents/AFR-RC50-9%20Promoting%20the%20role%20of%20traditional.pdf

13. Ministério da Saúde. Secretaria de Vigilancia em Saúde. Departamento de Análise de Situação de Saúde (2012) Saúde Brasil 2011: Uma análise da situação de saúde e a vigilancia da saúde da mulher. Editora do Ministério da Saúde, Brasília.

14. Comissão Económica das Naçães Unidas para áfrica (2013) Relatório sobre os ODM de 2013: Avaliação do Progresso de áfrica rumo aos Objectivos de Desenvolvimento do Milénio.

15. Nações Unidas (2014) Relatório sobre os Objectivos de Desenvolvimento do Milénio de 2014.

16. Revista Âmbito Jurídico (2023) Instituições varejistas e jurídicas se unem para tirar empreendedores fluminenses do vermelho. https://ambitojuridico.com.br/

17. Bustreo, F., Say, L., Koblinsky, M., Pullum, T.W., Temmerman, M. and Pablos Méndez, A. (2013) Ending Preventable Maternal Deaths: The Time Is Now. The Lancet Global Health, 1, e176-e177. https://doi.org/10.1016/S2214-109X(13)70059-7

18. Morse, M.L., Fonseca, S.C., Barbosa, M.D., Calil, M.B. and Eyer, F.P. (2011) Mortalidade materna no Brasil: O que mostra a produção científica nos últimos 30 anos? Cadernos de Saúde Pública, 27, 623-638. https://doi.org/10.1590/S0102-311X2011000400002

19. Ministério da Saúde. Secretaria de Vigilancia em Saúde. Departamento de Análise de Situação em Saúde (2009) Guia de vigilancia epidemiológica do óbito materno. Ministério da Saúde, Brasília.

20. Mendes, M., Barbosa, J., Loureiro, E. and Ferreira, M.A. (2014) How Medical Education Can Contribute towards the Reduction of Maternal Mortality in Angola: The Teaching/Learning Process of Gynecology and Obstetrics. African Health Sciences, 14, 228-236. https://doi.org/10.4314/ahs.v14i1.36

21. Gil, A.C. (2008) Como elaborar projetos de pesquisa. 4th Edição, Atlas, São Paulo.

22. Matias, J.P., Parpinelli, A.A., Nunes, M.K.V., Surita, F.G.C. and Cecatti, J.G. (2009) Comparação entre dois métodos para investigação da mortalidade materna em município do sudeste brasileiro. Revista Brasileira de Ginecologia e Obstetrícia, 31, 559-565. https://doi.org/10.1590/S0100-72032009001100006

23. Krebs, V.A., Da Silva, M.R. and Bellotto, P.C.B. (2021) Síndrome de HELLP e mortalidade materna: Uma revisão integrativa. Brazilian Journal of Health Review, 4, 6297-6311. https://doi.org/10.34119/bjhrv4n2-184

24. Kassebaum, N.J., Barber, R.M., Bhutta, Z.A., Dandona, L., Gething, P.W., Hay, S.I., et al. (2017) Global, Regional, and National Levels of Maternal Mortality, 1990-2015: A Systematic Analysis for the Global Burden of Disease Study 2015. The Lancet, 388, 1775-1812. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5224694

25. Medeiros, L.T., Sousa, A.M., Arinana, L.O., Inácio, A.S., Prata, M.L.C. and Vasconcelos, M.N.G. (2018) Mortalidade materna no estado do Amazonas: Estudo epidemiológico. Revista Baiana de Enfermagem, 32, e26623. https://doi.org/10.18471/rbe.v32.26623

26. Rahman, B.M., DaVanzo, J. and Razzaque, A. (2014) Pregnancy Termination in Matlab, Bangladesh: Maternal Mortality Risks Associated with Menstrual Regulation and Abortion. International Perspectives on Sexual and Reproductive Health, 40, 108-118. https://doi.org/10.1363/4010814

27. Scarton, J., Thurow, M.R.B., Ventura, J., da Silva, D.N., Perim, L.F. and de Siqueira, H.C.H. (2020) Maternal Mortality: Causes and Prevention Strategies. Research, Society and Development, 9, e67953081. https://doi.org/10.33448/rsd-v9i5.3081

28. Chola, L., Pillay, Y., Barron, P., Tugendhaft, A., Kerber, K. and Hofman, K. (2015) Cost and Impact of Scaling up Interventions to Save Lives of Mothers and Children: Taking South Africa Closer to MDGs 4 and 5. Global Health Action, 8, Article No. 27265. https://doi.org/10.3402/gha.v8.27265

29. Tayler-Smith, K., Zachariah K., Manzi M., Van den Boogaard, W., Nyandwi, G., Reid, T., et al. (2013) Achieving the Millennium Development Goal of Reducing Maternal Mortality in Rural Africa: An Experience from Burundi. Tropical Medicine & International Health, 18, 166-174. https://doi.org/10.1111/tmi.12022

30. Martins, A.C.S. and Silva, L.S. (2018) Perfil epidemiológico de mortalidade materna. Revista Brasileira de Enfermagem, 71, 725-731. http://www.scielo.br/pdf/reben/v71s1/pt_0034-7167-reben-71-s1-0677.pdf

31. Scarton, J., Paula, S.F. andrade, G.B., et al. (2019) Perfil da Mortalidade Materna: Uma Revisão Integrativa da Literatura. Revista de Pesquisa Cuidado é Fundamental Online, 11, 816-822. https://doi.org/10.9789/2175-5361.2019.v11i3.816-822 http://www.seer.unirio.br/index.php/cuidadofundamental/article/viewFile/7063/pdf_1

32. Teixeira, N.Z., Pereira, W.R., Barbosa, D.A. and Vianna, L.A. (2012) Mortalidade materna e sua interface com a raça em Mato Grosso. Revista Brasileira de Saúde Materno Infantil, 12, 27-35. https://doi.org/10.1590/S1519-38292012000100003

33. Riquinho, D.L. and Correia, S.G. (2006) Mortalidade maternal: Perfil sóciodemográfico e causal. Revista Brasileira de Enfermagem, 59, 303-307. https://doi.org/10.1590/S0034-71672006000300010

34. Guimarães, T.A., Rocha, A.J., Rodrigues, W.B. and Pasklan, A.N. (2017) Mortalidade materna no Brasil entre 2009 e 2013. Revista de Pesquisa em Saúde, 18, 81-85.

35. Martins, A.C. and Silva, L.S. (2018) Epidemiological Profile of Maternal Mortality. Revista Brasileira de Enfermagem, 71, 677-683. https://doi.org/10.1590/0034-7167-2017-0624

36. Santos, K., Batista, M.A., Paula, M.R., Gonçalves, R.C. and Reis, S.S. (2020) Infecção puerperal e mortalidade materna. Revista Científica Multidisciplinar Núcleo do Conhecimento, 5, 98-110. https://doi.org/10.32749/nucleodoconhecimento.com.br/saude/infeccao-puerperal