BY REBECCA SLUTSKY
Brazil has the largest economy of all Latin American nations. Despite its economic status and its efforts to improve the health of its citizens, morbidity and mortality statistics remain shockingly high. Nearly 50% of babies are delivered by caesarean section, leading to C-section related complications. Furthermore, over a million illegal abortions are performed each year, suggesting that one in four pregnancies are terminated. Maternal mortality rates (MMRs) are also five to ten times higher in Brazil than in countries of similar economic status. 1 These distressing statistics display the deficiencies of the health care system created by the sociopolitical environment of Brazil. Significant regional disparities within Brazil’s poor northern and relatively wealthy southern regions result in socioeconomic differences and unequal access to quality health care. As a result, improving the health system to reduce the high frequency of caesarean sections and illegal abortions represents a major challenge for maternal healthcare in Brazil. If Brazil succeeds, it would reduce MMRs to an acceptable level and measurably improve the health of mothers throughout Brazil.
With its tremendously large and ethnically diverse population, Brazil is the fifth largest landmass and eighth largest economy in the world. 2 Historically, its size and diversity have contributed to its substantial health and wealth inequities. The population is heavily concentrated in the south and southeast regions, which hold 115 million inhabitants and 56.5% of the population. The northeast also contains 53.5 million inhabitants and 28.2% of the population. 3 The two regions with the largest land area, the center-west and north regions, together make up 64% of the landmass of Brazil, yet they contain only 15.2% of the population, or 29.1 million people. 4 The poorest regions of Brazil are found in the north and northeast.
In the past five decades, Brazil has evolved from a predominantly rural society to one in which 84% of the population lives in urban centers. Many of these cities, such as Sao Paulo, Rio de Janeiro, and Belo Horizonte, are located in the Southeastern region. 5 The Brazilian population identifies itself as approximately 48% White, 44% Pardo (brown), 7% Black, and 0.3% indigenous. 6 The majority of Whites live in the southeastern region, while the majority of Blacks live in the northeastern region. The indigenous people form the majority of the population in the north, northeastern, and center-western regions. The huge disparity of wealth in Brazil, a product of its sheer size and diversity, has greatly affected access to health care in the poorer and more remote regions of the country. The maternal mortality rates in the poorest, northeastern part of the country, for example, are significantly higher than those in the south and southeast. 7
As a country with a Catholic majority, Brazil has strict anti-abortion laws. Only women who have been raped or who might die from their pregnancy may induce abortions. Brazil even requires judicial permission for severe fetal malformations such as anencephaly. 8 In order to prevent illegal abortions, Brazil has set the sentence for illicit abortion at one to ten years in prison. 9 The illegality of abortion has not slowed the rate of abortions in Brazil, however, but has instead contributed to unsafe practices and limited the reliability of abortion statistics. In 2010, a national survey of urban cities concluded that 22% of women between the ages of 35-39 reported inducing an abortion. 10 In 2008, abortion related complications accounted for 215,000 hospital admissions, of which only 3,230 were from legal abortions. 11 Estimates suggest that 22% of abortions, or roughly one in five, result in hospitalization. This statistic suggests that more than one million induced abortions were performed in 2008. 12 In that same year, three million babies were born in Brazil. 13 Though not all illegal abortions result in death, or even abortion-related complications, women of lower classes face the greatest danger. Poor women do not have access to the same quality of health care as members of the upper class, lacking access to basic clean facilities and trained medical professionals. Some women may even decide to induce abortions by themselves. Due to socioeconomic inequality, poor black women in Brazil are also three times more likely to die from unsafe abortions than white women. 14
In an attempt to ensure better access to quality maternal care and lower MMRs from abortion, the Brazilian government passed Provisional Measure 557 in 2012. 15 This law created a registry of pregnant women and allowed them to access funding for prenatal care. Some worry, however, that the provision will potentially prevent women from getting abortions, leading to more unsafe abortions and increased rates of maternal mortality. 16 Other Catholic Latin American countries, such a Mexico and Argentina, have made substantial progress in reducing abortion-related MMRs. These countries have refocused the debate upon medical statistics that study the social and health effects of illegal abortions in order to advocate for the sexual, reproductive, and basic health rights of women. 17
In addition to the high rates of abortion related morbidity and mortality, the number of caesarian sections performed each year is dangerously high. Nearly 50% of babies are delivered by c-section. 18 As access to better prenatal care and the likelihood of giving birth in a health facility have increased over the past 20 years, so has the use of caesarean sections and episiotomies. Brazil has the highest C-section rate in the world, with an average of 35% of patients in public hospitals and 80% of patients in private hospitals undergoing the procedure over the past 20 years. 19 Yet the World Health Organization requires that the rate of medically necessary caesarean sections in any given population never reach higher than 15%, because the possibility of excessive bleeding, blood clots, infections, and complications from anesthesia makes C-sections much riskier than vaginal births. 20 The unnecessarily high rate of caesarian sections in Brazil contributes dangerously to the high rate of maternal morbidity and mortality.
Is the high rate of caesarean section due to medical preference or to women’s demand? Some argue that the culture in Brazil promotes the procedure, increasing the rate to abnormal levels. Women schedule caesarean sections to avoid the pain and physical changes that accompany vaginal delivery. In addition, Brazilian doctors have been accused of pressuring women into this otherwise unnecessary procedure merely for their own convenience. In the 1970s, as the procedure was gaining fame, doctors and hospitals earned more for the procedure than they did for vaginal delivery. 21 This pay gap contributed to the increasing frequency of caesarean sections. To counteract that trend, Brazil instituted equal pay for all types of deliveries in 1980, but the change only temporarily halted the growth of the C-section rates. 22 The government implemented other policies in 1998, 2000, and 2005, but again, they only temporarily slowed the increasing trend. 23 The upward trend still does not seem to show any signs of reversing, and it continues to contribute significantly to Brazil’s high mortality rates. In contrast, a decrease in income also comes with a decrease in the number of C- sections, as low income hinders access to health services. The small beach town of Itacare, for example, has limited healthcare, because its location in the north of Brazil is over 1.5 hours from the nearest city. Itacare has a hospital with a maternity ward, but that ward is not equipped to perform C-sections. Pregnant women who are able will most likely travel to Ilheus, the nearest city, to give birth, because they do not want to risk finding themselves without the option of an emergency caesarean section. Traveling and waiting to give birth in Ilheus is expensive, so mothers often ask for or accept C-sections instead of waiting for vaginal births. Unfortunately, because regional public hospitals in the north have higher C-section related mortality rates than private hospitals in the south, undergoing this procedure in Ilheus is relatively risky. In addition, many women who cannot afford the travel expenses will simply stay in Itacare, where they cannot access a potentially life-saving medical procedure. As a result, both the high caesarean section rate and the lack of access to necessary caesarean sections contribute to Brazil’s high MMRs.24
The Millennium Summit of the United Nations addressed the high rates of MMRs in Brazil and throughout the world in 2000 by establishing Millennium Development Goal 5 (MDG 5). 25 MDG 5 required that Brazil reach maternal mortality rates of no more than 35 deaths per 100,000 live births. 26 Estimating MMRs in Brazil, however, is a tricky process. First, the only recent data on MMRs are limited or inaccurate. In addition, estimates of maternal mortality vary widely because they rely upon a number of different methods for calculation. 27 Under-registration of deaths, especially in rural areas and small towns where mortality ratios tend to be highest, as well as the underreporting of maternal causes of death, have decreased only slightly because of new auditing procedures. 28 A maternal mortality survey taken in all state capitals in 2010 estimated the MMR in Brazil to be an average of 54.3 deaths per 100,000 live births, a number that ranged from 42 in the south to 73 in the northeast. 29 This rate of progress fails to satisfy the requirements of MDG 5, and the goal of 35 deaths per 100,000 live births remains out of reach. Significant regional disparities worsen the unequal access to health care that exists between the north and northeast regions and the south and the southeast regions.
Although Brazil’s MMR is still too high, especially when compared with those of neighboring countries like Chile, Argentina, and Uruguay, Brazil has achieved advances in maternal healthcare in the past two decades. Improved socioeconomic conditions and the reform of the health sector have created positive changes. Since the 1990s, government policies have focused on social protection mechanisms that include the promotion of social inclusion in all sectors of society. The establishment of the Unified Health System (SUS), the Community Health Worker Programme, and the Programme of Integrated Care for Women’s Health (PAISM) have helped improve women’s sexual and reproductive health. 30 Women’s movements have also initiated the creation of new policies, such as the 2000 National Programme for the Humanization of Antenatal, Delivery, and Post-Partum Care. Furthermore, a 2005 ruling encourages the presence of an assistant during labor in public hospitals to provide independent support for mothers. 31
In addition, several initiatives have improved surveillance and reporting of maternal deaths. Maternal mortality committees now exist in all municipalities of Brazil. Many Non-Governmental Organizations (NGOs) also focus on improving maternal health and education. A key health reform measure has been the decentralization of healthcare. An ecological analysis of 2,700 municipalities accounting for 89% of the Brazilian population showed that the municipalities with the greatest decentralization and primary health care expansion also exhibited the largest decrease in mortality rates from 1998 to 2006. 32 These health programs turned their focus on the unique sociopolitical climates of the particular regions they served, resulting in improved patient care. The use of contraceptives and the level of antenatal care coverage have both increased, as well as the presence of skilled attendants at deliveries of every socioeconomic group. These changes all indicate Brazil’s efforts to improve equitable access to essential reproductive health services. 33
Even as Brazil attempts to reduce socioeconomic differentials in health care, the magnitude of the poor-rich gap in maternal health is still larger than that of other countries of similar economic status. Illegal abortions and unnecessary caesarean sections represent only two examples of the challenges Brazil must address in order to improve its health care system and deal with fundamental sociopolitical issues. The most pressing challenge now is providing access to the most remote regions of Brazil; for example, the rural populations in the Amazon rainforest and northeast regions where up to 10% of Brazilian municipalities do not even have access to a physician. 34 Brazil must increase its efforts to strengthen its health care systems and reduce socioeconomic disparity in order to achieve measurable improvements in maternal health.
Rebecca Slutsky is a sophomore in Silliman College. Rebecca is an undeclared major from New York. She can be contacted at rebecca.slutsky@yale.edu.
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References:
1. Victora, C.G., Aquino, E.M., do Carmo Leal, M., Monteiro, C.A., Barros, F.C., & Szwarcwald, C.L. (2011). Maternal and child health in Brazil: progress and challenges. Lancet, 377(9780), 1863-1876.
2. Barros, F.C., Matijasevich, A., Requejo, J.H., Giugliani, E., Maranhão, A.G. … Victora C.G. (2010). Recent trends in maternal, newborn, and child health in Brazil: progress toward Millennium Development Goals 4 and 5. Am J Public Health, 100(10), 1877-1889.
3. Vanderiei, L.C.M. & Paulo, G.F. (2015). Advances and challenges in maternal and child health in Brazil. Rev. Bras. Saude Mater. Infant., 15(2).
4. Brazil: Maps, history, geography, culture, facts, guide, travel/holidays/cities. (n.d.). Retrieved from http://www.infoplease.com/country/brazil.html.
5. Ibid.
6. Barros et al., 2012.
7. Cecatti, J.G. & Parpinelli, M.A. (2011). Maternal health in Brazil: priorities and challenges. Cad. Saude Publica, 27(7).
8. Brazil: Maps, History, Geography, Culture, Facts, Guide, Travel/Holidays/Cities, n.d.
9. Limoncelli, M. (2012). International women’s issues: Maternal mortality in Brazil. Persephone Magazine. Retrieved from http://persephonemagazine.com/2012/04/international-womens- issues-maternal-mortality-in- brazil/.
10. Victora et al, 2011.
11. Limoncelli, 2012.
12. Victora et al, 2011.
13. Ibid.
14. Ibid.
15. Limoncelli, 2012.
16. Ibid.
17. Vanderiei & Paulo, 2015.
18. Limoncelli, 2012.
19. Victoria et al, 2011.
20. Barros et al, 2010.
21. Behague, D. (2002). Beyond the simple economics of cesarean section birthing:women’s resistance to social inequality. Cult Med Psychiatry, 26(4), 473-507.
22. Britto, J. (2013). Maternal health in Brazil and the myth of choice. Feminist Midwife. Retrieved from http://www.feministmidwife.com/2013/05/02/maternal-health- in-brazil-and-the- myth-of- choice-guest- post-by- juliana-britto/#.VhmgwukxhBQ.
23. Victora et al, 2011.
24. Ibid.
25. Behague, 2002.
26. Limoncelli et al, 2012.
27. Cecatti & Parpinelli, 2011.
28. Limoncelli et al, 2012.
29. Barros et al, 2010.
30. Ibid.
31. Victora et al, 2011.
32. Diniz, S.G., D’Oliveira, A.F., & Lansky, S. (2012). Equity and women’s health
services for contraception, abortion and childbirth in Brazil. Reprod Health Matters,
20(40), 94-101.
33. Limoncelli et all, 2012.
34. Victora et al, 2011.
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