Re-estimating maternal mortality in Brazil from 2010 to 2024, by ethnicity and education

Introduction

Maternal mortality in Brazil exhibits pronounced racial disparities, which may be underestimated because of differential identification of maternal deaths by ethnicity. This study assessed trends in maternal mortality rates (MMR) inequalities in Brazil after applying a correction factor for maternal deaths missed because of incomplete death investigation.

Methods

An ecological time-series study was conducted using national mortality and live-birth data from 2010 to 2024. A standardized correction factor was estimated based on the four Brazilian states with the highest proportion of investigated deaths reclassified as maternal deaths. The factor was applied to re-estimate annual maternal deaths by state, ethnicity, and education. Observed and corrected MMRs (per 100,000 live births) were calculated by ethnicity and education. Relative risks (RRs) and 95% confidence intervals were estimated to assess inequalities in MMR.

Results

From 2010 to 2024, there were 1,038,921 deaths among women of reproductive age (10 to 49 years), and 19,136 original maternal deaths. In the same period, 42,053,253 live births were recorded. After applying the correction factor, estimated maternal deaths increased to 27,611.8 (+44.3%), corresponding to 565.1 additional maternal deaths per year. Mean period MMR increased from 45.6 to 65.8/100,000 live births, peaking in 2021 at 120.7 per 100,000. Higher RRs were observed in Black and Indigenous mothers, and among those with up to 7 years of education.

Conclusions

Correcting for incomplete investigation and reclassification substantially increased maternal mortality estimates and highlighted pronounced inequalities among Black, Indigenous, and women with lower education levels, supporting more equity-focused monitoring of maternal mortality targets and reinforcing the need to address underlying social and health-related determinants.

Key messages

• Assessment of inequalities in maternal mortality in low resource settings (e.g. Brazil) can be problematic because of differential reporting of ethnicity.

• Applying a correction factor based on states with the highest proportion of investigated deaths reclassified as maternal deaths revealed large inequalities by ethnicity and education.