At a time when the world is facing an unprecedented pandemic, all aspects of human life in this year 2020 are deeply affected. The disease designated as COVID-19, caused by the new coronavirus (SARS-CoV-2) has not only changed our ways of organizing life but also, given its high transmissibility and lethality, how we organize and respond to health care. In this context, assistance in prenatal care and childbirth has also changed in the face of the enormous challenges posed within health services. In Brazil, the new coronavirus adds to a set of problems that women already face in exercising their reproductive rights, within a culture that prioritizes what anthropologist Robbie Davis-Floyd (1992) has labelled “the technocratic model “of medicalized childbirth assistance. Among the consequences of this model even BEFORE the pandemic struck were the extremely high number of caesarean sections (most unnecessary) that occur each day, obstetric violence, and a high risk of complications during childbirth, leading to what that the medical literature refers as “near miss”, that is, where the woman has a near brush with death (Diniz et al. 2016; Diniz & Chacham 2004; Leal et al., 2014. McCallum 2005).

All this unfolds within a healthcare system characterized by inequality, structural racism and sexism, and a consequent lack of access to health services adequate for women’s needs during pregnancy, birth and the post-partum period. In March 2020, little information was available on the particularities of pregnant or postpartum women infected with SARS-CoV-2. However, as the months have passed, pre-existing problems in Brazilian obstetric care have become the allies of the new coronavirus and the already high rate of maternal mortality is set to increase – indeed is already on the rise. We say this based on past records. According to the Maternal Mortality Monitoring Panel of the Ministry of Health of Brazil, two thirds of maternal deaths in the last five years were caused by direct obstetric causes, that is, causes that could be avoided in over 90% of cases. Under the present circumstances, this means that women already have great difficulty in accessing health services in a timely manner so as to avoid complications during pregnancy and / or childbirth. COVID-19 can only make this situation much worse.

Here is why we think this is so: Pregnant women under prenatal care should be regularly monitored and need to leave home for consultations and tests. Even before the pandemic, Brazilian women – above all those who use SUS, the free national healthcare system – faced difficulties in accessing adequate tests and services, leading to unnecessary complications during pregnancy, childbirth or the puerperium. Now these health services have been reorganized, as a response to the pandemic, with a reduction in services, and the introduction of remote consultations or else their simple postponement. As a result, there are fewer consultations and laboratory tests taking place. Consequently, surveillance and detection of complications has been reduced, most likely significantly.

Pregnant women’s responses are also contributing to this tendency. They suffer increased levels of anxiety and fear, as they watch daily media reports on the seriousness of the world situation in the face of the pandemic. Health authorities recommend that people stay at home as much as possible, avoid social contact, wear a mask and only go to the health service if it is extremely necessary. In the face of all of this, pregnant women may delay seeking medical help even when there is a change in their health status, simply because they believe they are protecting themselves from the coronavirus. However, they end up at greater risk of suffering complications.

Therefore, even though remote consultation strategies are purportedly available, though not always possible for obstetric care, it may be that women have chosen to avoid prenatal care. They will, however, seek hospital care for childbirth, since home birth is no longer an option for the vast majority of women in this nation (Carneiro 2015.). Consequently, the fear of a coronavirus infection, whose risk group includes pregnant women and women who have recently given birth, adds to the old barriers to good hospital care, such as obstetric violence, racism, low quality of care and the veritable via crucis women using the public system face when they go into labour and need to find a maternity hospital with a bed available for them (McCallum & dos Reis 2005) . Reproductive rights conquered with great difficulty, such as the presence of a companion and humanized assistance for childbirth and birth, are easily dismantled in view of the inability of obstetric health services to readjust to the new coronavirus.

All of this circumscribes the therapeutic itinerary of pregnant and puerperal women looking for assistance.  Their journeys in search of care can set them on the “road of death”, either because of the new risks of the new coronavirus, or because of the old causes of maternal death linked to hypertension, haemorrhages, infection and, in Brazil, illegal abortion which still raises the number of unnecessary maternal deaths each year (Menezes et al. 2020). Once again, the health service that should be a place to save lives becomes a place of yet greater danger. Obviously, not all women are affected equally. Particular social groups are at greater risk. According to epidemiologist Emanuelle Góes, unequal access to goods, services and opportunities based on skin colour makes racism normative, even though racism is considered a crime under Brazilian law. In the national health service racism operates institutionally for it is a system in which skin colour impacts the provision of an adequate health service – or lack thereof (Góes 2020; Góes et al. 2020). Women of colour suffer worse outcomes in comparison with whites for the same health needs, under the same physical conditions and with comparable access to supplies and equipment.

The new coronavirus, as a common enemy of the whole world, comes to impose new rules of coexistence and healthcare.  However, it comes burdened with the old enemies of health equity listed above, such that its negative impact is proving greater for more vulnerable populations, especially all those who are oppressed under systems of inequality and structural racism. Researchers in Brazil who are documenting these processes, like our colleagues at MUSA/ISC/UFBA, are demanding that policymakers and health providers work to guarantee women’s reproductive rights, including high-quality prenatal and postnatal care, and that they provide all who need it the means to experience a safe and respectful childbirth. To do this it will be necessary to organize specific clinics for pregnant women who test positive for coronavirus, and engage in a wider initiative aimed at ending structural racism and sexism.

References

Davis-Floyd, R. E.  1992. Birth as an American Rite of Passage. Berkeley: University of California Press.

Diniz, C.S. G., Niy, D.Y, Andrezzo, H.F.de A., Carvalho, P.C.A., & Salgado, H. de O. 2016. A vagina-escola: seminário interdisciplinar sobre violência contra a mulher no ensino das profissões de saúde. Interface – Comunicação, Saúde, Educação, v.20, n.56, p.253-259.

Diniz, C.S. G & Chacham, A.S. 2004. “The Cut Above” and “the Cut Below: The Abuse of Caesareans and Episiotomy in São Paulo, Brazil. Reproductive Health Matters, v. 12, n. 23, p. 100-110.

Góes, E.F. 2020. https://catarinas.info/colunas/racismo-e-desigualdades-o-que-ha-de-democratico-na-covid-19/ (accessed 6 of June 2020)

Goes, E.F., Ramos, D. de Oliveira & Ferreira, A.J.F. (2020). Desigualdades raciais em saúde e a pandemia da Covid-19. Trabalho, Educação e Saúde, 18(3), e00278110. Epub May 29, 2020.https://dx.doi.org/10.1590/1981-7746-sol00278

Leal, M. do C., et al. 2014. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cadernos de Saúde Pública, n.30. Supl. 1, p. S17-S32.

McCallum, CA. 2005. Explaining Caesarean Section in Salvador da Bahia, Brazil. Sociology of Health and Illness. v.27. n.2. p.215-242.

McCallum, C. A., & Reis, A.P. dos. 2005. Childbirth as Ritual in Brazil: Young Mother´s Experiences. Ethnos 70 (3) 335 – 360.

Menezes GMS, Aquino EML, Fonseca SC, Domingues RMSM. 2020. Abortion and health in Brazil: challenges to research within a context of illegality. Cadernos de Saúde Pública, no.36. Suppl 1: e00197918. doi:10.1590/0102-311X00197918

Leonildo Severino da Silva: Obstetric Nurse; Doctoral Student in Public Health Studies at ISC-UFBA (The Collective Health Institute, Federal University of Bahia), Brazil; Associated to MUSA- The Gender and Health Studies Program – at ISC-UFBA. Researcher in the field of social sciences and humanities in health. Current research is focused on the therapeutic itineraries of women who experienced maternal near miss (near death during or as a result of pregnancy) associated with the intersectionality of race, gender and class in an anthropological perspective. Previous research on themes related to violence against women, reproductive health care of indigenous Kambiwá women.

Cecilia Anne McCallum: Professorial Fellow, Department of Social Anthropology, University of St. Andrews. Associate Professor, Department of Anthropology and Ethnology, UFBA, Brazil; Professor in the Postgraduate Program in Collective Health, ISC- UFBA; Member of MUSA- The Gender and Health Studies Program – at ISC-UFBA.

IMPLICATIONS OF COVID-19 FOR PRENATAL CARE AND CHILDBIRTH IN BRAZIL, Cecilia McCallum and Leonildo Severino da Silva