Finding a topic for these columns is always a bit of a mixed bag. Sometimes there’s an obvious issue to write about, sometimes a friend forwards me a news article or similar, with “you should write about this!” in the headline. (Note: dear friends, thank you, and please do not stop.) And sometimes I begin by googling “women’s rights in [wherever]” and seeing what floats to the surface, knowing approximately which sub-region I’d like to cover. This week was the latter, but as soon as I read an RH Reality Check piece that pointed out that the maternal mortality rate in Brazil was five to ten times higher than countries with a similar economic status, I knew I had my topic for the week.
So. 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.”
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.
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.
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.
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.
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.
There is a lot of attention being paid to this issue, by the government, the international community, and by local women’s groups. The first two – government and international NGOs are more than a little linked. Millennium Development Goal* number five is maternal health, which they’ve broken into two goals: reduce maternal mortality by ¾ from 1990 to 2015, and achieve universal access to reproductive health. Seeing as Brazil is interested in increasing its role in the global community, the government is working hard to reach the MDGs, especially this one, as several high-profile maternal deaths have garnered international attention in recent years. President Rousseff gave the opening speech to the UN General Assembly this year, and in it, she called for Brazil to be given a permanent seat on the Security Council, so Brazil at the moment is giving high priority to the MDGs.
To this end, there are now government maternal mortality committees in all 748 municipalities, responsible for documenting, reporting and investigating maternal mortality rates. There is also the problematic registry of pregnant women explained above, though as this law was only passed a few months ago, it’s not yet possible to see what impact it will have.
Women’s rights groups, however, have been trying to reduce the MMR for decades, before the international community made this a hot topic. BEMFAM, the Family Well-Being Civil Society, is a 46 year-old women’s rights NGO, and one of the largest NGOs in the country. Their work focuses on reproductive health, especially in marginalized populations. They have 6,620 reproductive health centers throughout the country, providing reproductive and sexual health services to millions each year. In addition to this outreach and other such programs, they conduct surveys and studies and provide information via trainings and education, on a truly massive scale. In 2007, they brought 1,700 government and non-government organizations in Brazil together to focus on maternal mortality, and increase communication (and therefore effectiveness!) of all these different groups. Look at the sheer size of this organization!
Focusing specifically on unsafe abortions, there is AADS, or Affirmative Action in Human Rights and Health, founded by Dr. Leila Adesse. Formerly associated with Ipas, the international organization devoted to promoting safe abortions, AADS’s express purpose is to reduce maternal mortality due to abortion. Research states that more than a million illegal abortions are performed in Brazil every year. The illegality alone doesn’t make them fatal, the problem is that upper class women can afford to have their abortions performed in clean facilities with trained staff, as opposed to impoverished women, whose abortions are performed in much more dangerous conditions. And due to socio-economic inequalities Afro-Brazilians are three times more “vulnerable to death from unsafe abortions.” AADS addresses all of this, via advocacy work, training, equipment distribution, and awareness campaigns. And while they work hard to reduce the need for abortion, they also prioritize making abortions safe and hygienic – no matter the poverty level of the woman in need of one.
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. Amazingly, the website Maternal Health Task Force put together an interactive map, showing all the related NGOs (both big and small) that they could find:
Brazil’s a big country, there are a lot of groups. Some, like Reprolatinas, a women’s rights group in Sao Paulo, focus on reproductive and sexual health, with gender equality as a means towards that goal – their work focuses on combating gender inequality as well as increasing information about and access to women’s healthcare. Others, like the Center for Women’s Studies Urban and Rural, focus on equality first, and see women’s health as a path towards true equality. Either way, the focus on reproductive health means that these organizations are also joining the fight to improve maternal health.
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.
Are Women’s Rights on the Agenda in Latin America?
BEMFAM’s population strategies
Brazil Works to Reduce Unsafe Abortions
The Brazilian Society for Family Welfare
Center for Women’s Studies Urban and Rural
Dilma Thumps For Women
Maternal and child health in Brazil: progress and challenges
Maternal Mortality Ratio, per 100 000 live births
Organizations working in Maternal Health
Will Brazil’s Maternal Registration Law Reduce Maternal Mortality?
*I’ve written about the MDGs before, I believe, but essentially, they are 8 goals created by Jeffery Sachs and the UN to try and dramatically improve the global quality and equality of life. The goals are broken up into quantifiable statistics with targeted numbers and due dates ““ “cut poverty rates in half by 2015″ etc.