EDITORIAL

Maternal health in Brazil: priorities and challenges

José Guilherme Cecatti; Mary Angela Parpinelli

Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brasil. cecatti@unicamp.br

The UN member states convened at the Millennium Summit in 2000 agreed that the world has sufficient technology, resources, knowledge, and experience to deal with the majority of the problems that prevent "human development for all", particularly for people in poor and developing countries.

Brazil is a signatory to the Millennium Declaration, and the most recent Brazilian National Progress Report on the Millennium Development Goals points to important strides, especially in the fight against extreme poverty and hunger, the reduction of infant mortality, and the struggle against diseases like HIV/AIDS, malaria, tuberculosis, and leprosy. However, forecasts are bleak for achieving the goal of improved maternal health. Despite progress, the inequalities are striking. Gender, ethnicity, place of birth, and social class are still determinants of future opportunities for Brazilians, with direct repercussions on women's health and the maternal mortality ratio (MMR). The latter is one of the most complex public health indicators and is highly sensitive for revealing both women's position in society and access to and quality of sexual and reproductive health services. To achieve the goal of improved women's health, Brazil must reach a maternal mortality ratio of no more than 35 deaths per 100 thousand live births, while the forecast for 2015 (estimated in 2008) points to values ranging from 69 to 77 maternal deaths per 100 thousand live births. This trend emphasizes the need to revise the related action strategies.

A paradox emerges when one confronts Brazil's coverage of prenatal and childbirth services with the country's MMR. According to data from the National Demographic and Health Survey (PNDS) for 2006, 89% of pregnant women in Brazil attended at least four prenatal visits, and 83% had their first prenatal visit while still in the first trimester. A full 98% of the births took place in hospital, the vast majority of which attended by formally qualified professionals (89% were physicians). The Unified National Health System (SUS) accounted for 76% of all the deliveries in the country, but the estimated MMR for that year was 72 deaths per 100 thousand live births. Where does the problem lie? There is some indirect evidence of problems with professional qualifications and the quality of the obstetric care provided, such as the incidence of 12 thousand cases of congenital syphilis in the year 2004 and the high perinatal component within overall infant mortality.

Improved maternal health based on reducing the MMR is a current priority and challenge for Brazil. In addition to guaranteeing a well-structured health system, functioning at the three levels of care, the first major strategy is to adopt and implement standardized intervention packages based on strong scientific evidence and recognized by health institutions, professional societies, and regulatory bodies, the use of which can be performed and demanded by trained and competent professionals. The second major strategy would be to disseminate the study of severe maternal morbidity ("near miss"), which has been suggested by international agencies as a useful approach for investigating the quality of the obstetric care system, thereby contributing effectively to the reduction of maternal mortality.

This strategy of investigating "near misses" is capable of revealing flaws or delays in obstetric care and/or in the integration between different levels of care. A woman who has experienced near death and recovered can contribute (almost in real time) to the elucidation of "delays" in her obstetric care. The identification of such cases through a prospective surveillance system for severe maternal morbidity/near miss in maternity hospitals, which has already proven possible in a recent Brazilian experience, should be confirmed as a useful strategy for improving maternal health in Brazil.