Maternal Death in the Metropolitan Region of Belém, Pará – Brazil, between 2013 and 2017

Objective: The present study aims to identify maternal deaths in the Metropolitan Region of Belém do Pará, Brazil, between the years 2013 to 2017 and to analyze the clinical-epidemiological profile of these women with maternal death. Method: This is a retrospective epidemiological, descriptive study with a quantitative approach, conducted in February 2020, with information from secondary data from the Mortality Information System (SIM). Results: Between 2013 and 2017, 142 maternal deaths were found in the metropolitan region of Belém, with the highest number of cases occurring in 2013, with a total of 38 maternal deaths. As for the clinical-epidemiological profile, there was a predominance of the age group between 20 to 29 years old, brown race and single marital status. Most deaths occurred during the puerperium, in a hospital setting and cause of death from pregnancy, childbirth or the puerperium.Conclusion: In view of this, actions are needed to promote the improvement of living conditions and assistance to women of reproductive age,both in preventing unwanted pregnancies and in preventing complications during the period of pregnancy and the puerperium. International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-7, Issue-3, Mar2020] https://dx.doi.org/10.22161/ijaers.73.40 ISSN: 2349-6495(P) | 2456-1908(O) www.ijaers.com Page | 272 Keywords—Maternal deaths, women's health, pregnancy.


I. INTRODUCTION
Maternal mortality (MM) is defined by the World Health Organization as the death of a woman during pregnancy or within 42 days after the end of pregnancy, regardless of duration or location, due to any probable cause with or aggravated by pregnancy or by measures in relation to it, but not by accidental or incidental causes (WHO, 2012).
Currently, the global maternal mortality rate is about 210 deaths per 100,000 live births. According to the Epidemiological Surveillance Guide for Maternal Death, the reduction in the maternal mortality rate in the world and, especially in Brazil, still represents a major challenge for health and society. Despite advances in decreasing rates, high mortality rates from preventable causes have been observed that affect Brazilian regions in different ways (WHO, 2015; Ministry of Health Brazil, 2009). In Brazil, there was a reduction of approximately 56% in the maternal mortality ratio, between 1990 and 2015. In 2016, 1.463 cases were recorded, which represented a 16% decrease in relation to the previous year, but it still remains high when compared to developed countries (Ministry of Health Brazil, 2018).
The causes of maternal mortality can be direct, such as: obstetric complications in the pregnancy-puerperal period resulting from injuries, omissions, incorrect treatment or sequence of events in any of these situations and indirect, resulting from pre-existing diseases or during treatment during pregnancy and that were aggravated by their physiological effects (PAHO, 2018).
Maternal death is a strong indicator of a country's socioeconomic conditions and the quality of life of the population, expressing a devaluation and disrespect for life, or that can be translated as a provision of low quality humanitarian assistance. In addition, it indicates a country's "political determination" to carry out "collective and socialized actions" in this segment, constituting an indicator of social inequities (Souza, 2015).
Given this reality, the new Sustainable Development Objetivos which followed the Millennium Development Goals, emerged with the goal of eliminating maternal mortality from preventable causes, between the years 2016 and 2030. In Brazil, the target is reduced to approximately 20 deaths for every 100,000 live births (United Nations, 2015).
Based on the above, the present study aims to identify maternal deaths in the Metropolitan Region of Belémdo Pará, Brazil, between the years 2013 to 2017 and to analyze the clinical and epidemiological profile of these women with maternal death.

II. METHOD
This is an epidemiological, descriptive retrospective study, with a quantitative approach, carried out in February 2020 with secondary data information from the Mortality Information System (SIM), referring to maternal mortality in the metropolitan region of Belém in the State from Pará, between the years 2013 to 2017. The data collected are available for public consultation at DATASUS -Information Technology at the Service of SUS, at theelectronic address http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt1 0uf.def . SIM is a system of regular data search on mortality in Brazil. From it, it is possible to capture data on mortality, in a comprehensive and reliable way, to subsidize different scales of public health management. Based on this information, it is possible to carry out situation analysis, planning and evaluation of actions and programs in the area.
For this study, data were collected on 142 cases of maternal deaths in the metropolitan region of Belém do Pará, on the SIM website. The metropolitan region covers the municipalities of Ananindeua, Belém, Benevides, Castanhal, Marituba and Santa Izabel, between 2000 and 2017. The following sociodemographic variables (total number of cases; age group; race and marital status) and Epidemiological variables (death during pregnancy or puerperium; place of death; investigated death and cause of death (CID-10).
From the collected data, a descriptive analysis of the studied population was performed, the data are arranged in tables, using statistics related to the median and standard deviation of the selected variables. The use of open data is available to the public and is available for consultation on the DATASUS -SUS Service Information Technology website, without the need for an estimate by the Research Ethics Committee.

III. RESULTS
Between 2013 and 2017, 142 maternal deaths were found in the metropolitan region of Belém, with the highest number of cases occurring in 2013, with a total of 38  Source: MS / SVS / Mortality Information System -SIM, 2020.
As for the clinical-epidemiological profile of women with maternal death in the metropolitan area, there was a predominance of the age group between 20 and 29 years old, with 63 cases (44%), 107 were of brown race (75%) and were single (39%). Regarding death during pregnancy or the puerperium, 101 cases (71%) occurred during the puerperium, 138 cases (98%) were in the hospital, 132 (93%) with an informed summary form and in 132 cases (93%) the cause of death (ICD-10) is related to CAP XV -Pregnancy, childbirth or the puerperium. Table 2 expresses the characterization of the clinicalepidemiological profile.

IV. DISCUSSION
When analyzing the data of this study, it was found that between 2013 and 2017 142 maternal deaths were reported in the metropolitan region of Belém. It was found that the largest number of cases occurred in 2013 with 38 deaths, showing a decrease in following years, reaching a total of 19 deaths in 2016. However, in 2017 the number of deaths increased, reaching 29 deaths.
The municipality of Belém has the highest number of deaths, with 92 cases (65%), the result is similar to a study that evaluated the epidemiological profile and causes of maternal mortality in the State of Pará between the years 2012 to 2016, stating that among 18 municipalities in Pará, the city of Belém suffered 99 deaths. In addition, it showed that among the regions of the State of Pará, deaths are concentrated mainly in the Metropolitan Region, with a total of 254 cases (Miranda, Botelho, Tsuchiyama, Luz, &Veras, 2019). The mortality rate was predominant in the age group between 20 and 29 years, as in a study that characterized the epidemiological profile of maternal deaths in the reference hospital for high-risk pregnancies, without qualifying the total of 47.3% of maternal deaths in the same age group (Menezes, Bezerra, & Bezerra, 2015). This fact can be explained by the fact that it is the peak of reproductive age and represents the period in which women become pregnant due to greater fertility, thus increasing the number of maternal deaths in this age group considered young (Szwarcwald, Escalante, Rabello Neto, Souza Junior,& Victora, 2014).
Other aggravating factors for cases of mortality in this age group may be the higher frequency of family rejection due to pregnancy, the presence of social and economic restrictions, low schooling and absence of previous gynecological consultations, when comparing the older age groups, or those who can increase maternal morbidity and mortality (Passos et al., 2016).
As for race, the highest maternal mortality rate occurred in women of the brown race. This finding is similar to the study carried out by Carvalho et al (2016), who, when characterizing maternal deaths in a northeastern Brazilian municipality, found that 46% of maternal deaths occurred in women of brown race.
Brown women, as well as black women, are more vulnerable to maternal death, due to factors related to biological predisposition to diseases such as hypertension / pre-eclampsia. In addition to the genetic factor, they are the most prevalent breeds in Brazil, mainly in the state of Pará, which has great indigenous and African influence, being During the pregnancy 41 29% During the postpartum period 101 71% When analyzing marital status, it was found that 39% of maternal deaths occurred in single women. The study by Martins & Silva (2018) in Juiz de Fora -MG, also showed a prevalence of deaths in single women with 57.66%. Note that the presence of a partner can bring safety, speed and access to the most effective and efficient health services, avoiding serious complications that can cause death. Thus, the presence of the partner in the pregnancy-puerperal period can be considered a protective factor in reducing maternal morbidity and mortality (Vega, Soares,& Lourenço, 2017).

Place of Death
As in a study conducted in Bahia (43.1%), deaths in the puerperium prevailed, with a total of 101 cases, totaling 71% (Coelho, Andrade, Sena, Costa,& Bittencourt, 2016). The puerperal period is a phase that requires attention from professionals, with primary care being held two postpartum consultations, in which these professionals must check and guide women as to the appearance of signs and symptoms that may indicate complications, such as fever, pain or infection in episiotomy or cesarean section, intense vaginal bleeding, among others (Brasil, 2012).
The place of death, as in the study by Carvalho et al (2016) (78%), was in the hospital environment with 97% of cases of maternal deaths. This study corroborates that the hospital stay of most women occurred less than 24 hours, which indicates a delay in seeking care. Factors such as the precarious functioning of services, together with the presence of incapacity for a correct diagnosis, upon admission, can lead to the evolution of the case to death (Miranda, Botelho, Tsuchiyama, Luz,& Veras, 2019).
Among the main causes of maternal deaths is the Specific Hypertensive Syndrome of Pregnancy (SHEG), which is highly prominent throughout Brazil. A study by Camacho (2017) found greater emphasis on hypertension, a result that contributed to a percentage of 56.60% of maternal deaths from direct obstetric causes (in 2013, 57.78% in 2014 and 60% in 2015). Data from the Ministry of Health also show hemorrhages, infections, complications of hypertensive syndromes and abortion, in addition to thromboembolic problems and anesthetic accidents, comorbidities in maternal deaths (Brazil, 2009).

V. CONCLUSION
In this study it was possible to identify that maternal deaths in the metropolitan region of Belém showed a decrease in cases, however it still has high rates. Most of the pregnant women who died were between 20 and 29 years old, brown race and single. Most deaths occurred in the hospital during the puerperium, and the cause was related to pregnancy.
The decrease in maternal deaths is directly related to the improvement in living conditions and assistance to women of reproductive age, both in terms of preventing unwanted pregnancies and preventing complications during the period of pregnancy and the puerperium. For this, procedures are needed to reduce cases of maternal deaths based on preventive measures, comprehensive family planning, which causes the occurrence of unwanted pregnancies, adequate prenatal care, qualified staff to assist in obstetric emergencies and with frequent use puerperal.