Pregnant women who have to travel to give birth face higher infant mortality risk, research shows

Every day, countless pregnant women have to go long distances for medical appointments, tests and even to give birth. These trips, which are often aimed at preventing complications and caring for the health of pregnant women and their babies, can have a more serious impact than you might think. A study by Fundação Getulio Vargas’ Center for Empirical Economics Studies (FGV CEEE) found an increased chance of mortality when analyzing the impact that travel for childbirth can have on health outcomes in newborn babies. The study also warns of the need to create public policies to improve this situation.

The research found that 31% of mothers in Brazil travel an average of 59 km to go to a maternity hospital and the probability of mortality is 0.5 percentage points higher for babies whose mothers go this distance to give birth. The study also shows that the distance traveled by mothers has increased in recent years, when looking at the period from 2006 to 2017.

In addition, the probability of mortality is around 2 percentage points higher for babies whose mothers travel more than 100 km, compared to those who travel no more than 50 km. According to the authors, the most worrying thing about this situation is that this risk increases progressively. It is estimated that for every additional 10 km of travel, there is an increase in the mortality rate of around 0.10 deaths per thousand live births.

To arrive at these results, the researchers used several administrative health databases in Brazil together with regression models to treat the data, with the aim of investigating the effect of the distance traveled for childbirth on infant mortality.

Access barriers

FGV CEEE coordinator Valdemar Pinho Neto, who led the study, points out that around 30% of all births in Brazil take place outside the mother’s home municipality. “This fact constitutes a public health problem, given that some of the deaths caused by long journeys could have been avoided.”

Although the availability of facilities suitable for perinatal care in the public health system improved between 2007 and 2021, Pinho Neto stresses that the public health system is supposed to offer everyone the same quality of care, but Brazil’s geography makes it difficult for access to childbirth services to be the same.

“There are no hospitals available near these mothers, who end up having less access than others. In addition, our research found two relevant issues: the first is that births have increasingly taken place in public health system facilities with greater technological capacity and infrastructure, and the second is that the distance to these health facilities is much greater than the distance to other facilities. So, the challenge for the public health system is to ensure that mothers have access to health services, and also that these services have the necessary resources to provide high-quality care,” Pinho Neto says.

Inequality between Brazil’s regions

According to the researcher, this issue of mothers traveling is even more critical if we look at regional inequalities, since the proportion of mothers who have to leave their municipalities to give birth is even higher in the northeast of the country. In Pernambuco, for example, around half of mothers leave the municipality where they live to give birth in another one.

In the North region, although going to a different municipality to give birth is less frequent, it is necessary to bear in mind that the northern states tend to have large municipalities, and as Pinho Neto warns, the distance traveled can be immense.

“If a mother lives about 150 km from a hospital, she and the local health manager have to decide whether to deliver the baby in the municipality, even though there might only be very basic conditions there, or to travel, which could also have consequences not only for the birth of the child but also for maternal health. These factors have an inherent complexity that requires us to look at all the dimensions,” he says.

On the other hand, journeys for childbirth tend to be shorter for pregnant women in the South and Southeast regions, where there is generally a more structured network based on established “health micro-regions,” which receive patients from the surrounding municipalities.

“In these two regions, the maternity hospital networks are better distributed and people don’t tend to travel as much,” says the professor. He believes this is an important point, given that the public health system was created to serve all Brazilians equally, but geographical distance is one of the factors preventing this ideal from being fully realized.

The study also shows that proximity to public health centers with better infrastructure reduces infant mortality in high-risk pregnancies, even after isolating the effects of other risk and sociodemographic factors. Pinho Neto believes that the relationship between the distance traveled by mothers and infant mortality in Brazil is complex, but research like this can provide a warning and guide the creation of public policies.

Additional risk

“On the one hand, going 50 km usually doesn’t take you into a different municipality in the North region, but on the other hand, there are hospital hubs that allow mothers to have better access to services in certain locations. Public managers need to take this data into account when making their decisions and rethink policies to reduce infant deaths that could be avoided,” he says.

Recent infant mortality data shows that the largest proportion of deaths occur up to one year of age, with around 11 deaths per 1,000 live births. “Most of these deaths happen in the first few days of life and from preventable causes,” says Pinho Neto.

The professor also notes that the long journeys made by pregnant women are often accompanied by stressful situations and waits for appropriate treatment. This factor makes these journeys themselves an additional risk, even in pregnancies and births that in principle are low risk.

“In our conversations with health managers and mothers who had to travel, we heard all kinds of stories. For example, some mothers go to another municipality the day before giving birth and others stay with friends or acquaintances. In addition to these conditions, some wait for contractions to start before traveling,” Pinho Neto says.

Socioeconomic inequalities

In addition to geographical inequality, the study also looked at the socioeconomic profile of mothers who make these journeys to hospitals in other municipalities. It was found that in places with a higher level of human development, living conditions and access to education, mothers travel shorter distances on average.

Conversely, mothers who live in poorer municipalities with lower levels of education tend to go longer distances. In the researcher’s view, improving access to hospitals in the locations where the most vulnerable people are found would be an effective way to help achieve the ideal of equity in the public health system.

The study found that mothers in locations with poorer socioeconomic conditions also have to face the adverse factors imposed by the distances traveled to a maternity hospital, increasing the potential negative effects of travel on maternal and infant health.

For example, in the municipality of Itaeté in Bahia, average monthly per capita income is R$224 and the average distance to a maternity hospital is 57 km. In the municipality of Botelhos in Minas Gerais, monthly per capita income is R$630 and pregnant women have to travel around 35 km to give birth. Both municipalities have a population of around 15,000 inhabitants.

“The municipalities in which pregnant women travel the farthest to a maternity center tend to be those with the worst socioeconomic indicators. In other words, the distance they travel further reinforces the inequalities in our country, which are also evident in access to health care,” says Pinho Neto. In his view, this point is significant because although the study focused on the role of distance, it is not the only factor that affects the chance of infant mortality.

“Distance traveled has an influence, but all the socioeconomic, demographic and other issues need to be considered together. If you don’t improve vulnerable people’s access to hospitals, their quality of life will be affected,” he says.

Distance from facilities

As well as looking at the distance women travel to maternity hospitals, the study also examined their conditions, such as intensive care beds, specialized health professionals and medical equipment, among other hospital attributes that are relevant to maternal and neonatal care. It was found that the farther away a high-risk pregnant woman is from the level of care she needs, the greater the chance of her baby dying.

In the Northeast and North regions, these distances are also much greater than in other regions. On average, pregnant women in the Northeast live 45 km away from facilities needed for intermediate perinatal care, such as ultrasound scanners. In the North, the average distance is 73 km. For some items, such as a neonatal intensive care bed, the distances are often even greater.

In some cases, Pinho Neto says that the distance to specific types of equipment can be so great that it discourages demand, as it is practically inaccessible. “If a pregnant woman is 500 km away from a facility or service, it’s likely that she won’t be seen there, either because she doesn’t know anyone in the area or because she doesn’t have the means to get there in a timely and safe manner,” he says.

In addition, the proportion of pregnant women who go to another municipality to give birth is exacerbated when they or their babies have risk factors, as all these effects combined can increase the risk of mortality. “If a pregnant woman has a certain condition that needs specific treatment and for this treatment she needs equipment that is very far away, the intention to treat the condition may be prioritized, along with the availability of the equipment nearby,” he says.

These and other results of the research were presented at an event in Brasilia attended by representatives of the National Council for Scientific and Technological Development (CNPq) and the Bill and Melinda Gates Foundation, which funded the study.

You can read the full article here.