DID YOU KNOW that the maternal mortality ratio is one of the most sensitive indicators of poverty and social inequity?

Ana Isabel Paraguay
Posted April 30, 2013 from Brazil
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* "Why is the maternal mortality rate so high, and what is being done to address this? First of all, maternal mortality is defined by the World Health Organization as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” This, honestly, was not the formal definition I anticipated, because of the phrase “termination of pregnancy” — which includes births, miscarriages, and abortions. I was under the impression that abortion-related deaths would be tallied separately, but apparently this is not the case. So that’s going to be an interesting element to examine. And, as usual here, when I say “interesting” I mean “potentially heartbreaking.” [1]

"Overall, the evidence [...] reviewed showed that use of maternal health care varied greatly both within and between countries. Within countries, urban or wealthier women were usually more likely to deliver with the help of a skilled health worker than were rural or poor women. Urban women were more likely to use medical settings for delivery than were rural women. In some countries, wealthier women tended to deliver in medical settings, but in others (e.g. Guatemala and Tajikistan) economic status did not affect such practices. The association between place of residence and receipt of early antenatal care was not consistent. Some evidence suggested that wealthier women were more likely than poorer ones to receive early antenatal care, although no such difference was found in India." [2]

"This review demonstrates variations in the use of maternal health care across populations both within and between 23 developing countries. Variations were partly explained by methodological differences in study designs. However, important and diverse contextual factors were also identified, many relating to the funding and organization of health care. In addition, more subtle, but equally influential, context-specific individual level factors emerged, as did interactions between individual level and health service-related factors. Two reasons for the limited success of the safe motherhood campaign during the past two decades have been the lack of rigorous analysis of the data available on variations in use, together with an inadequate grasp of the contextual issues that must be addressed if inequalities in maternal health care use are to be reduced. Our results highlight the need to thoroughly explore and address context-specific causes of variable use of maternal health care if safe motherhood is to become a reality in developing countries." [2]

"In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5·5% a year in the 1980s and 1990s, and by 4·4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974—75 to 7% in 2006—07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2·5 months in the 1970s to 14 months by 2006—07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age." [3]

" The reasons behind Brazil's progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women's health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries." [3]

"Let’s begin with an overview of women’s rights in Brazil in general, which is a complicated topic, made moreso by the diversity of cultures within Brazil, as well as the sheer size of the country’s population. (Is there any place where women’s rights AREN’T complicated, though?) Brazil is rapidly becoming a more prosperous and “developed” country, and women’s rights are evolving as well. The overall culture is heavily patriarchal, due to both the colonial influence and the strength of the Catholic church in the country, and this negatively impacts women’s health, employment, inheritance rights (in some cases), political representation, and overall equality. Brazil ranks 84th on the Gender Inequality Index, a composite statistic involving maternal mortality, adolescent fertility, parliamentary representation, educational attainment beyond primary school, and labor force participation. At the same time, there is and has been a strong women’s rights movement in Brazil for decades. Currently, the President of Brazil is Dilma Rousseff, the first woman to be elected president of that country. She has repeatedly vowed to improve women’s rights in Brazil, particularly in the field of political representation. Additionally — and notably — the average fertility rate has rapidly decreased in Brazil, from an average of six children per woman in the 1960s to an average of slightly less than two, though this is partially due to the popularity of voluntary sterilization in impoverished areas, which brings with it a whole host of complications. Overall, though, this implies readily available access to contraception, and a high level of education and health awareness among women." [1]

" While positive changes are occurring, let’s look at maternal mortality specifically — namely, the contributing causes for Brazil’s disproportionately high rate. Recent statistics say that more than 4,000 women die from pregnancy and childbirth-related causes in Brazil every year, and that one in ten of these deaths are due to unsafe abortions. Specific causes of death include hypertension, sepsis, hemorrhage, and complications from abortion." [1]

"Abortion is illegal in Brazil with exceptions for rape and endangering the life of the mother, and partially because of that, there is, on average, at least one woman dying every day due to an unsafe abortion. A new law was recently passed, ostensibly to reduce maternal mortality, which creates a registry of pregnant women, allowing these women to access money that can be used towards prenatal care. At the same time, the idea of a national registry of pregnant women is cause for concern, as it could easily be used to prevent women from accessing abortion. Which, in turn, would lead to more unsafe abortions, and therefore increase the maternal mortality rate. Problematic." [1]

" Aside from abortion-related deaths, there is a very high rate of caesarean section births — between 40 and 50 percent of all births in Brazil are via c-section. Obviously, some caesarean sections are necessary, but according to WHO, necessary c-sections should be around 15%, and almost half of Brazil’s c-sections were scheduled in advance. The last thing I’m going to do is pass judgment as to the manner in which a woman chooses to give birth, but specialists agree that this high c-section rate is a contributing factor to Brazil’s disproportionately high maternal mortality rate." [1]

" There is also a huge disparity of wealth in the country, and this, of course, impacts access to health care and the ability to pay for said health care. The maternal mortality rates in the northeastern part of the country — the most impoverished — are significantly higher than those in the south and southeast." [1]

"There are literally dozens, if not hundreds, of smaller women’s rights NGOs in Brazil, many of which are founded and run by women, and dedicated to improving maternal health. " [1] "Maternal mortality rates are starting to decrease in Brazil, and with the continuing work of these organizations, as well as international scrutiny and support, it is a safe bet that this disproportionately high maternal mortality rate will soon be a thing of the past. As Brazil moves forward with this effort, however, they must take care to ensure that well-intentioned efforts (such as the registry) do not ultimately cause more harm to women than good." [1]


"Recent statistics say that more than 4,000 women die from pregnancy and childbirth-related causes in Brazil every year, and that one in ten of these deaths are due to unsafe abortions." [1]

The health and nutrition of Brazilian children has improved rapidly since the 1980s. A key indicator of Millennium Development Goal 1 (a reduction in the number of underweight children by half between 1990 and 2015) has already been met and Millennium Development Goal 4 (a two-thirds reduction in mortality rate of children younger than 5 years by 2015) will probably be met within the next 2 years. [3]

Progress in maternal mortality ratios is diffi cult to measure because time trends are distorted by improvements in vital statistics, but evidence exists of a decrease in maternal mortality ratios in the past three decades. However, Millennium Development Goal 5 (a reduction in maternal mortality by three-quarters between 1990 and 2015) will probably not be met. [3]

Regional and socioeconomic inequalities in intervention coverage, nutrition, and health outcomes in Brazil have largely decreased. [3]

The main factors that drive such trends probably include improvements in social determinants (ie, poverty, education of women, urbanisation, and fertility), non-health-sector interventions (ie, cash transfers, water, and sanitation), and the creation of a unifi ed national health system with geographical targeting for primary health care (giving previously underserved populations better access to health care), in addition to disease-specifi c programmes. [3]

Major challenges exist, including a reduction of the high frequency of caesarean section, illegal abortions, and preterm births, in addition to achieving further reductions in regional and socioeconomic inequalities in health. [3]


[1] Limoncelli, Mary Anne. International Women´s Issue: Maternal Health in Brazil. Persephone Magazine, 04-10-2012. Available from http://persephonemagazine.com/2012/04/10/international-womens-issues-mat...Access: April 30, 2013.

[2] Say Lale, Raine Rosalind. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ [serial on the Internet]. 2007 Oct [cited 2013 Apr 30] ; 85(10): 812-819. Available from: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862007.... http://dx.doi.org/10.1590/S0042-96862007001000019.

[3] Victora, Cesar G; Aquino, Estela ML; Leal, Maria do Carmo; Monteiro, Carlos Augusto; Barros, Fernando C; Szwarcwald, Celia L. Maternal and child health in Brazil: progress and challenges The Lancet - 28 May 2011 ( Vol. 377, Issue 9780, Pages 1863-1876 ) DOI: 10.1016/S0140-6736(11)60138-4. Available from http://www6.ensp.fiocruz.br/repositorio/sites/default/files/arquivos/Mat...

NOTE: all texts are quotes from the references above. Please remember to put the right citations if you use these statements and/or stats anywhere!"

eMagazine: Maternal Health

Comments 4

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May 01, 2013
May 01, 2013

Dear Anaisabel,

this write up is well researched. Kudos, and i applaud also the NGOs working on maternal mortality and child right in Brazil. For us here in Nigeria, it is easy at all with all the political intrigues at play here but some day we will be able to say yes, we are making enough progress. we are working and we will continue to let the light shine.

Ana Isabel Paraguay
May 01, 2013
May 01, 2013

Please note I just selected and posted the citations - all duly referenced! The sources and their authors are the real writers. I just had the time, patience and good eyes to search for such articles and extract the best part (of many) of them to compose this patchwork of key ideas about the subject. I hope it also helps to enlighten and point out key facts about the matter as it did for me.

May 01, 2013
May 01, 2013

I have shared it to World Wide Women a minute ago, and recommended it here - stuff like this are gemstones to me, so thank you for writing it! Much love, Ruth

Ana Isabel Paraguay
May 29, 2013
May 29, 2013

and even more for forwarding my posting.