The unacceptable tragedy of maternal mortality associated with COVID-19: (re)politicization of women’s health and rights and the position of Brazilian nursing

In 2020, the year designated as “The International Year of the Nurse and the Midwife”, the Nursing Now strategy ⁽¹⁾ further justifies the re-existence of nursing, with strategies, innovative and transformative actions in facing new challenges that are imposed, especially, from the context of the COVID-19 pandemic.

Brazilian nursing workers - at the frontline of care in research and teaching - have made efforts for the Brazilian population’s health and strengthened the Unified Health System (SUS – Sistema Único de Saúde). It is worth mentioning that, in the women’s health field, midwifery has been placing itself, with other actors, at the forefront of action in the movement for the humanization of childbirth and delivery. Such movement gained concreteness in a broader field with the creation of ReHuNa (Network for the Humanization of Childbirth and Delivery) in 1993; and, in the specific midwifery field, the Brazilian Association of Midwives and Obstetric Nurses (ABENFO - Associação Brasileira de Obstetrizes e Enfermeiras Obstetras) was founded in 1992.

Nursing and midwifery have been acting, in line with humanization movement for childbirth and delivery actions and demands, within the scope of professional practice and training, in teaching and in research, in order to transform the biomedical, interventionist and hierarchically-verticalized obstetric model. Midwifery has been promoting, in conjunction with other actors/entities, public policies in the childbirth and delivery field; in alignment with the 1988 Federal Constitution, SUS guidelines, and specific health policies in fields that intersect with maternal health, sexual and reproductive health and women’s health.

These trajectories place nursing and Brazilian midwifery - health workforce composed of more than 2.3 million workers ⁽²⁾ - mostly formed by women (85.1%), young people (78% are between 26 and 50 years old) and who declare themselves black or mixed-race (53%) ⁽³⁾ , in a position to make a call to (re)politicization of health and women’s (and men’s) reproductive sexual rights at a time when the COVID-19 pandemic threatens women’s health and rights.

The world is experiencing a challenging scenario that has been taking over the planet since the World Health Organization (WHO) declared, on January 30, 2020, the public health emergency of international concern, due to the outbreak of the new coronavirus (COVID-19), which was recognized on March 11, 2020 as a pandemic. Data from August 28 indicate that, to date, 24,316,245 cases of coronavirus infection have been confirmed, with a daily incidence of approximately 300,000 cases and more than 800,000 deaths. The Americas region concentrates approximately 50% of confirmed cases (12,865,897) and more than half of deaths (454,786) ⁽⁴⁾ , with Brazil emerging as the epicenter of COVID-19.

Among all reported cases in the Americas, Brazil accounts for approximately one third of the cases (3,761,391) and about one fourth of the deaths (118,649) ^(5-6) . Brazil ranks second in number of cases, behind only the United States, which has 5,902,374 cases of coronavirus and 181,435 deaths ⁽⁶⁾ .

In fact, there is a dramatic picture because the COVID-19 pandemic hits the country at a time when we would need to have strong health information, communication, research, science and technology systems, and investments in health work, in addition to social and state public policies. In contrast, what was imposed to meet ultra-liberal economic measures was the approval of a new tax regime, with Constitutional Amendment 95 and labor reforms by Law 13,467 of July 13, 2017 ⁽⁷⁾ and social security reforms, by Constitutional Amendment 103 of November 12 2019 ⁽⁸⁾ , the result of which has been high unemployment rates, increased violence, and especially against women - with an increased incidence of domestic and family violence. A reality that, on the one hand, restricts rights and, on the other, reproduces a process of normalization of social inequalities and injustices that mainly affects the most vulnerable social groups.

Additionally, COVID-19 continues to spread in Brazil, challenging us to overcome it in a surprising context, such as the fact that Brazil has become a unique case due to the high number of maternal deaths in this pandemic period, drawing international attention.

It is worth noting that in the country, until June 18, 2020, about 978 pregnant women and mothers had been diagnosed with the disease; of these, 124 (12.7%) died, with a large jump in the current maternal mortality rates, which were already quite high before the pandemic. COVID-19 is a disease with high speed of dissemination and with evidence that indicates that this population group requires special attention, as they develop more complicated conditions when compared to the group of non-pregnant women ⁽⁹⁾ .

According to the 10 ^th Revision of the International Classification of Diseases (ICD-10), maternal death is defined as death during pregnancy or up to 42 days after the end of pregnancy, and regardless of pregnancy duration or location, due to any cause whether it is related or aggravated by pregnancy or even by measures taken in relation to it, not due to accidental or incidental causes ⁽¹⁰⁾ .

It is noteworthy that in Brazil a Maternal Death Ratio (RMM) of about 59.1 per 100,000 live births (l.b.) persists, with direct causes predominating, respectively, hypertension, hemorrhage, infection and complications from unsafe abortion ⁽¹¹⁾ .

It is understood that if in 2018 the Maternal Mortality Ratio (RMM) was well below the target of 35 deaths for every 100 thousand l.b. established for 2015 by the United Nations (UN), in the current moment of the pandemic this concern rises further. The impact on morbidity and mortality caused by the new coronavirus causes deaths in population groups recognized as being at higher risk, such as pregnant women and women who have recently given birth, bringing up issues that affect women’s lives and health. This tragic reality indicates the need for (re)politicization of sexual and reproductive health and rights, as enshrined in the Brazilian Constitution and in the commitments signed by Brazil in international treaties.

Brazilian researchers in an international publication promoted in the scientific community, in the mainstream media and indeed in the Chamber of Deputies, revealed alarming data on the (cruel) intersection of gender, race and social class that, when intertwining, further deepen the tragedy of maternal deaths in the country. In the studied population, among the 207 (21.2%) cases admitted to Intensive Care Units (ICU), approximately 35% (73 cases) resulted in maternal deaths, 22.6% of women were not even admitted to an ICU and there was an absence of ventilatory support for 14.6% of these women ⁽¹²⁾ .

The study in focus also showed that the chance of black pregnant women dying corresponded to twice that of white women, indicating ethnic-racial disparity that reiterates the historical roots of social inequalities as well as the structural racism that has marked Brazilian society ⁽¹²⁾ .

Faced with this unacceptable reality of maternal deaths, national nursing organizations, represented by the Brazilian Nursing Association (ABEn – Associação brasileira de Enfermagem), ABENFO and the Federal Nursing Council (COFEn – Conselho Federal de Enfermagem), supported by the International Confederation of Midwives, recognizing their co-responsibility in overcoming the COVID-19 pandemic challenges for quality of life and health guarantee for women, issued a public note calling the competent authorities’ attention for immediate adoption of control measures, detection and early, timely treatment of pregnant women, and postpartum women resulting from the pandemic. Among them are: i) responsibility of the three spheres of government in the attention to women’s health and maternal health, with the definition of measures for immediate confrontation of the pandemic and post-pandemic; ii) investigation and analysis of deaths of women of childbearing age (WCA) and maternal deaths from Severe Acute Respiratory Syndrome (SRAG) and COVID-19 in multidisciplinary and interinstitutional technical chambers; iii) maintenance of the Health Care Network ( Rede de Atenção à Saúde) organized at its different levels, with guaranteed access, comprehensiveness and humanization of care; iv) decentralization of financial resources to prioritize the line of care for women; v) mandatory inclusion of obstetric nurses or midwives in an adequate number in all Brazilian maternities to act in the care of humanized childbirth and to participate in their representations in the technical chambers for monitoring maternal morbidity and mortality in hospitals, municipalities, states, and the Ministry of Health ⁽¹³⁾ .

The reasons why Brazil presents these alarming numbers of maternal deaths from COVID-19 are complex and multifactorial. Avoidable and preventable, these deaths of women, premature and unjustifiable, are a major public health and rights violation problem - sexual and reproductive rights. They opened up to disastrous implications of social, gender, race/ethnic inequalities as well as health system performance - still falling short of meeting women’s needs.

Therefore, it is inferred that all factors are relevant to forming a debasing and relentless picture of human rights violations, including the right to health and life, increased with the COVID-19 pandemic. It is urgent, then, that women’s demands in terms of sexual and reproductive life and health, inseparable from ethical, aesthetic, and political foundations, considering the seriousness of these challenges, be respected, strengthened and implemented in Health Care Network’s, services’ and care practices’ responses. Otherwise, women, their children, families and communities will remain under the misfortune of unnecessary and avoidable risks and deaths; that is why we call for political influence, with emphasis on (re)politicization in concrete terms of sexual and reproductive rights.

Along this path, executive and legislative branches authorities should provide the Union budget with sufficient funding for reproductive health, with a view to allocating resources for investments in scientific research, knowledge production and innovation in practice for training, continuing education and working conditions of nursing professionals and other health professionals. Additionally, in obstetrics, an approach based on human, sexual and reproductive rights to strengthen health policies and actions in a focus on gender, comprehensiveness and health promotion, is a fundamental measure to guarantee access expansion to safe, quality and resolutive care for women.

Brazilian nursing calls upon public policy makers, government officials, other health and nursing professional entities, health managers and professionals, universities and organized civil society, among others for the necessary and pressing (re)politicization of reproductive health. It is recognized that women experience risks associated with reproduction and experiencing their sexuality related to the way society takes care of them or not. Restrictive measures to guarantee women’s reproductive rights, for instance, especially to the group of women who depend exclusively on SUS, contrary to public policies, technical guidelines and contumacious practice in primary or specialized care and the regulation of nursing that guarantees insertion Intrauterine Device (IUD) by nurses, obstetricians and/or midwives duly trained and trained to do so ^(14-16) . These measures, in the same measure that hinder accessibility of women to qualified professionals, go against the legal practice of nurses and midwives. Contrary to strengthening women’s (and men’s) health, this type of measure harms multidisciplinary teamwork, disorganizes the (still few) services that offer reproductive planning actions with nurses and midwives acting on the front line and weakens comprehensive care to women’s health and the Health Care Network.

Another relevant issue, which is among the main causes of maternal mortality in Brazil, is humanized and safe care for women in cases of abortion. The case of a girl victim of rape who got pregnant was emblematic, and her pregnancy was interrupted by a court decision, whose family had to enter a Witness Protection Program (Provita - Programa de Apoio e Proteção às Testemunhas, Vítimas e Familiares de Vítimas da Violência) established by Law 9.807/99. This situation when reached social networks shocked the country and sparked the debate about women’s and girls’ rights to have access to safe, humanized sexual and reproductive health, including legal abortion ⁽¹⁷⁾ .

A recent study revealed that there are still cultural and religious barriers to carry out voluntary termination of pregnancy authorized by law in cases of rape and when there is a risk of death for pregnant women since the 1940s, and in cases of anencephaly, a topic discussed, and endorsed in 2012 by the Federal Supreme Court (FSC). The authors emphasize the necessary investments in training health professionals since graduation and continuous training for professionals, and service and care network organization ⁽¹⁸⁾ . Teaching hospitals and universities are strategic, but the support of professional and scientific entities to these institutions is also essential. Therefore, it is an opportune and necessary moment to expand healthcare services to women victims of sexual violence and legal abortion as well as professional qualification to work in these services.

From this perspective, challenges call for ethical-political, technical-scientific, powerful and expanded actions in favor of strengthening SUS and its health workforce, which has great and important pillars in nursing and midwifery.

Finally, in this setting of challenges in which social justice, health, sexual and reproductive rights, new modes of engagement and political influence are related, it is important to reaffirm that our commitment is to promote equity in women’s health, which requires strengthening primary care, caring for and saving lives. This is a challenging path to Brazilian and worldwide nursing.

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Publication Dates

• Publication in this collection
  16 Oct 2020
• Date of issue
  2020