Letalidade hospitalar por aborto legal em comparação a outros procedimentos obstétricos realizados no Sistema Único de Saúde (SUS), entre 2000-2015

Abstract

Global initiatives to reduce maternal mortality seek to advance the protection of women's lives, the realization of sexual and reproductive rights, and the assurance of bodily autonomy. Evidence from U. S. studies, supported by consensus from the World Health Organization (WHO), confirms that legal abortion, when performed in safe environments, is extremely safe. The case- fatality rate (CFR) for childbirth was over 14 times higher than that for legal abortion (8.8 deaths per 100,000 live births versus 0.6 per 100,000 legal abortions) in the United States (1988–2005). However, there is a restrictive legal framework (permitted only in cases of life-threatening risk, sexual violence, or anencephaly), limited reliable data, and services that often use outdated techniques such as curettage, provided in a small number of facilities in Brazil. The gap between this restrictive Brazilian context and the global health literature motivated this study, which aimed to compare CFRs associated with three different gestational outcomes: Legal induced abortion, abortions under other circumstances, and childbirth. This retrospective cohort study used individualized data from the Brazilian National Health Database (BNS), covering women of reproductive age hospitalized within the Brazilian Unified Health System (SUS) from 2000 to 2015. To calculate the CFRs, the calculation divided maternal deaths by hospitalizations in each group and quadrennial, multiplying the result by 100,000. A Chi-square test of independence assessed whether the proportions of deaths differed among the three obstetric groups. Fisher's exact test assessed differences in the distribution of deaths by cause (direct and indirect) across the groups. For cases with a maternal death outcome following legal abortion, the life trajectories of the women who died were described. In the cohort, which included 19,285,704 women, CFRs differed significantly among the groups (46.4/100,000 for legal abortion, 17.3 for other abortions, and 16.6 for childbirths, p<0.001). The CFR for legal abortion remained higher than in the other groups across all analyzed quadrennials. The distribution of direct and indirect maternal deaths differed among the groups (direct causes accounted for 90.0% post-legal abortion, 86.2% post-other abortions, and 78.1% postpartum, p<0.001). The descriptive analysis of the 10 maternal deaths following legal abortion showed that eight occurred in high-risk contexts or in the presence of a prior complication. Curettage preceded death in eight women. In seven records, there were diagnostic inconsistencies (a mix of infectious and hemorrhagic causes) or indications of care failures associated with delayed access to the procedure. These findings reveal that in this group, legal abortion—despite being a right—had a paradoxically higher CFR than other abortions and childbirth. This does not mean the procedure is inherently unsafe but indicates serious flaws in implementation to it in the Brazilian health system. Barriers to access and the use of outdated techniques lead to delayed, higher- risk procedures. This underscores the urgent need to improve medical care and provide access to safe, WHO- recommended methods, such as Manual Vacuum Aspiration (MVA) and/or medical abortion regimens (mifepristone/misoprostol), replacing D&C (which remains the most common, yet non- indicated, technique). Our findings emphasize the importance of protecting women's health by guaranteeing that the right to legal abortion in safe, timely, and high- quality conditions.