# Maternal and late mortality trends, emphasizing the H1N1 and COVID-19 pandemics, in the state of Rio de Janeiro, Brazil, from 2009 to 2021

## TL;DR

The study examines how maternal and late maternal mortality rates in Rio de Janeiro, Brazil, changed from 2009 to 2021, including the impact of the H1N1 and COVID-19 pandemics.

## Contribution

The study uniquely evaluates the effect of pandemic years on maternal mortality trends using joinpoint regression analysis.

## Key findings

- Maternal mortality increased by 51.2% during the 2020/21 pandemic period after a prior decline.
- Late maternal mortality showed an overall upward trend, partly attributed to improved death investigation.
- Excluding pandemic years, maternal mortality would have remained stable despite prevention efforts.

## Abstract

Trends in maternal mortality (MMR) and late maternal mortality ratios (LMMR) were estimated, in periods with and without H1N1 and COVID-19 pandemics, in Rio de Janeiro, Brazil, from 2009 to 2021.

Ecological study of temporal trends. Data was obtained from the Mortality and Live Birth Information Systems. The annual MMR and LMMR per 100,000 live births (LB) were calculated and the trends were estimated using the joinpoint regression model.

In 2009, the MMR was 103.1, reaching 152.4/100,000 LB in 2021, with an annual reduction of 3.3% (95% confidence interval - 95%CI -5.5; -1.7) until 2019 and an increase of 51.2% (95%CI 23.5; 64.5) in 2020/21. Excluding the years of the COVID-19 pandemic, it was observed that an annual decline of 3.3% and, with the concomitant exclusion of the years of the H1N1 pandemic, stability. The LMMR were 8.3 (2009) and 22.2 (2021) per 100,000 LB, with an annual growth of 28.2% (95%CI 11.8; 47.8) until 2011, remaining stationary from 2011 to 2015, followed by an increase of 11.7% until 2021; with the exclusion of the final biennium, the trend is upward (3.8%) and also with the exclusion of the initial biennium, the trend became downward (7%) until 2014 and upward (8.2%) from then on.

There was a change in trend with the separate or joint incorporation of pandemic biennia: without pandemics, maternal mortality would be stationary, despite actions to prevent maternal deaths, and late maternal mortality, would be descending until 2014 and then ascending, crediting itself in part, to improving death investigation.

Estimar as tendências das razões de mortalidade materna (RMM) e mortalidade materna tardia (RMMT), em períodos com e sem as pandemias de H1N1 e COVID-19, no estado do Rio de Janeiro, Brasil, de 2009 a 2021.

Estudo ecológico de tendência temporal. Dados obtidos dos Sistemas de Informações sobre Mortalidade e Nascidos Vivos. Foram calculadas as RMM e RMMT anuais por 100 mil nascidos vivos (NV) e foi aplicado o modelo de regressão joinpoint para estimar a tendência.

Em 2009, a RMM foi 103,1, alcançando, em 2021, 152,4/100.000 NV, com redução anual de 3,3% (intervalo de confiança de 95% — IC95% -5,5; -1,7) até 2019, e ascensão de 51,2% (IC95% 23,5; 64,5) em 2020/21. Excluindo-se os anos da pandemia de COVID-19, observou-se declínio anual de 3,3% e, com a concomitante exclusão dos anos da pandemia de H1N1, estabilidade. As RMMT foram 8,3 (2009) e 22,2 (2021) p/100.000 NV, com crescimento anual de 28,2% (IC95% 11,8; 47,8) até 2011, mantendo-se estacionária de 2011 a 2015, seguida de ascensão de 11,7% até 2021; com a exclusão do biênio final, a tendência é ascendente (3,8%) e, com a exclusão também do biênio inicial, a tendência passou a ser descendente (7%) até 2014 e a seguir ascendente (8,2%).

Houve mudança de tendência com a incorporação separada ou conjunta dos biênios pandêmicos: sem as pandemias, a mortalidade materna seria estacionária, apesar das ações de prevenção do óbito materno, e a materna tardia seria descendente até 2014 e depois ascendente, creditando-se tais tendências em parte à melhoria da investigação de óbito.