EDITORIAL

The challenge of the millennium: maternal mortality in Brazil

Maria do Carmo Leal

Vice-President for Teaching, Information, and Communication, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil. duca@ensp.fiocruz.br

The maternal mortality ratio is one of the most sensitive indicators of poverty and social inequity. Calculation of the ratio requires complete, precise data on the number and causes of deaths in childbearing-age women, and such information is not easy to obtain. Despite this difficulty, the maternal mortality ratio still provides an excellent indicator of coverage and quality of medical and health care for a given population.

Brazil is one of the 189 countries that signed a commitment in 2000 to meet the so-called Eight Millennium Development Goals by the year 2015. The MDGs include a reduction in maternal mortality to less than a third of the levels prevailing in 1990. One of the problems for adequate monitoring of this goal is the low reliability of national health statistics.

A recent analysis by the Brazilian Center for Classification of Diseases of the World Health Organization, estimated the maternal mortality ratio at 75.9 per 100 thousand live births for Brazil as a whole and defined correction factors for the indicator for the country's five geographic regions. The study also identified wide variation in the maternal mortality ratio between State capitals (from 42 to 73.2 per 100 thousand).

Various strategies have been used to deal with maternal mortality as a serious public health problem. For example, since 1996, 90% of pregnant women in Brazil have access to prenatal care, and more than 50% complete more than seven prenatal visits. In addition, nearly all deliveries (97%) take place in hospitals.

Another important strategy used to reduce maternal mortality has been the creation of "maternal mortality committees". Launched in 1988 in São Paulo, the committees aim to improve the notification of deaths, determine their causes, and monitor their occurrence. By 2001, Brazil already had nearly 300 regional, municipal, and hospital-based maternal mortality committees, spread across all the regions of the country. Widespread mobilization of health workers and professional societies and organized civil society have led to the establishment of multi-institutional and multi-professional committees that express the ideals of social participation and control, as provided for under the Unified National Health System.

However, these efforts failed to lead to improvement in the maternal mortality ratio from 2002 to 2006. Despite advances in primary and hospital care for pregnant women, with improvement in the information system and a strong presence by the maternal mortality committees, the measures have fallen short of target in decreasing maternal mortality. The principal prevailing causes of death are still hemorrhages and arterial hypertension, both preventable by means of quality prenatal and childbirth care.

Thus, the challenges are still enormous for reaching the Millennium Development Goals to which Brazil is committed in relation to maternal mortality. There is a persistent need to: (a) achieve complete coverage for prenatal and childbirth care; (b) improve the quality of care provided during pregnancy and delivery; (c) decrease the complications resulting from unwanted pregnancy through an adequate reproductive health policy; (d) institutionally and politically empower the maternal mortality committees in order to better perform their roles; and (e) last but not least, support a new nationwide study to assess to what degree the correction indicator resulting from the 2002 study is still current and valid.