WHEN THE BABIES LOSE THEIR MOTHERS DUE TO PREMATURE DEATH

mortality: When the babies due to death. ABSTRACT Objective: I dentify in the published articles the main factors that cause premature maternal mortality in pregnant women or when they give birth. Method: This is an exploratory descriptive study in the search for scientific publications on causes of maternal death. The study took place from the beginning of August 2019 to September 2020. Platforms such as SCIELO, LILACS BVS were used and the selection criteria for the research bibliography were the eligibility and ineligibility of articles, theses and monographs. Thus, 20 studies on the subject “Maternal mortality, when the babies lose their mothers due to premature death” were selected for analysis. Results: Maternal death in Brazil is directly linked to the living conditions of the Brazilian female population, mainly to socioeconomic factors or lack of commitment to basic social assistance and health prevention. Among the measures to reduce the critical cases of maternal mortality, we can mention the specialized and humanized care, as well as accurate diagnoses so that afterwards care is sought and the worsening of the number of deaths is avoided. Thus, it is necessary to look more carefully at this critical health scenario as hundreds of cases could and can still be avoided, as long as more attention is given to women through preventive health care.


INTRODUCTION
The World Health Organization (WHO) defines maternal mortality as the death of a woman during pregnancy or within 42 days after the end of the pregnancy, due to any cause related to the pregnancy or due to factors related to it. Martins and Silva (2017) report that maternal mortality is one of the indicators of the health discrepancy between developed, developing and underdeveloped countries. However, the discrepancy between developed and developing countries was maintained. In developed countries, the lowest MRI rates were found, with 14 deaths for every 100,000 live births. In turn, in developing countries the RMM was 290 deaths for every 100,000 live births, with the majority of cases being concentrated on the continents of Africa and Asia. It should be noted that in Africa -Angola, one maternal death occurs for every 29 pregnancies and this rate of maternal mortality being one of the highest in the world. Morse et al (2011) reports that in Brazil the causes of maternal deaths, regardless of the region are hypertensive diseases and hemorrhage, alternating the position in some states, without analyzing the determinants of maternal deaths. Martins and Silva (2017) add that the direct obstetric causes are related to complications in pregnancy, childbirth or the puerperium due to inadequate treatment, bad practices and omissions. The indirect ones are those that result from diseases that already existed before pregnancy or in a pathology that developed during pregnancy without a direct relationship with obstetric causes, but that are aggravated by the specific physiological conditions of a pregnancy.
The RMME Specific Maternal Mortality Ratio showed relevant indices in single, widowed and judicially separated women and, it points out that among widowed women, rates of up to 62.9 in 100 thousand live births were observed, women declared judicially separated presented indices of 51 , 8 and single women had RMME rates of 70.8 per 100,000 live births.
The study shows that the woman's marital status and marital status contributes to a situation more vulnerable to maternal death and that the lack of a partner or husband can probably lead to insecurity and lack of family support. Thus, the presence of a partner in the pregnancy-puerperal period becomes a relevant protective factor in reducing maternal morbidity and mortality. (CARRENO, BONILHA, COSTA, 2011 To measure maternal mortality, its extent and predisposition in space and time, the Maternal Mortality Coefficient (CMM) is used as a health indicator. This indicator is evaluated by the number of maternal deaths for every 100 thousand Live Born Babies (BNV), and the limit of 20 deaths per 100 thousand live births is acceptable by WHO. (BOTELHO et.al, 2014). Martins et al, (2017) reports that in recent years some measures have been adopted in order to minimize the effects of underreporting on the prevalence of maternal mortality, obtained through data from the Mortality Information System (SIM).
Among them, the research process carried out by the maternal mortality prevention committees with a view to identifying the relationship between the basic cause of death and a possible pregnancy stands out.
Another strategy adopted is the research method called the Reproductive Age Mortality Study (RAMOS) developed to measure the number of underreported maternal deaths and calculate an adjustment factor for the correction of official data based on the death data of women of reproductive age. Vega et.al (2017) reports that simple but important measures such as reproductive planning, monitoring and treatment of cardiopathies in the puerperium, magnesium sulfate in pre-eclampsia and eclampsia, antibiotics in infection, safe abortion, oxytocin or misoprostol in post-hemorrhage-birth and professional training contribute to the reduction of the identified causes, thus guaranteeing the right to life for these women.
In Brazil, the main users of the Unified Health System (SUS) are women and, of these, 65% are between 12 and 49 years old (CARRENO; BONILHA; COSTA, 2011).
The avoidability of death means providing family structure and the construction of the mother-baby bond, providing the pregnant woman with exams and prenatal care throughout the pregnancy.

CAUSES OF MATERNAL MORTALITY
In many countries, pregnancy-related deaths are a major cause of death for women of For Costa et al (2011), the maternal mortality ratio in developing countries remains well above that recommended by the WHO (RMM below 20 deaths in 100 thousand live births). According to the WHO, mortality associated with the pregnancy-puerperal cycle and abortion does not appear among the top ten causes of death among women aged 10 to 49 years.
However, the seriousness of the problem is evidenced when related to healthy women in the reproductive period, these deaths being preventable in 92% of cases if the local health conditions are similar to those of developed countries.
It is observed that the main causes are hemorrhage, hypertension, sepsis, abortion and embolism. The challenge for reducing maternal mortality due to abortion is even greater, in view of situations such as clandestinity and illegality.
The World Health Organization (WHO) estimates that in 2008 about 13% of maternal deaths worldwide, equivalent to 47,000 were due to unsafe abortions. In Brazil, abortion is among the five main causes of maternal mortality and, it is related to approximately 5% of the total maternal deaths, for this reason, in the last years there has been a great discussion in the country about the decriminalization of abortion above all, involving a complex set of political, legal, moral, religious, social and cultural aspects (MARTINS et al, 2016).
Regarding indigenous women, Alves (2019) estimates that in Brazil the cause of death is related to the pregnancy-puerperal period, these deaths are possible to avoid in 92% of cases.
These cases are defined as maternal deaths and are characterized as violations of human rights and 99% of them occur in regions of greater poverty and higher levels of inequality, which is why maternal mortality indicators are important for assessing the living and health conditions of a population. Martins and Silva (2017) emphasize that the direct obstetric causes are related to complications in pregnancy, childbirth or the puerperium due to inadequate treatment and bad practices and omissions. The indirect ones are those that result from diseases that already existed before pregnancy or from a pathology that developed during pregnancy, without a relation to the direct obstetric causes, but that were aggravated by the specific physiological conditions of a pregnancy.
In this context, Lima et al (2017) says that in 2012 in Brazil the main direct causes of maternal death were hypertension (20.2%) and hemorrhage (11.9%) and among the indirect causes, the most frequent were diseases of the circulatory system representing (7.3%) of the total deaths. Mota et al (2012) reports that although the implications of dengue in the evolution of pregnancy have been poorly studied, some factors described by some studies have contributed to the identification of adverse outcomes that occurred in the health of pregnant women and their babies.
Since 1995, the Ministry of Health has included an option in the death certificate for women of childbearing age (10 to 49 years), so the doctor must indicate whether she was pregnant at the time of death or whether she was pregnant in the twelve months that before death. (PEREIRA, 2015).
According with Martins and Silva (2017), the literature describes that 95% of maternal deaths in the world could be prevented if public and private services expanded women's sexual and reproductive rights, in addition to ensuring safe and respectful obstetric care.
Even when the worst is avoided, some abominable sequelae remain and, therefore, it is estimated that for each maternal death, another 16 women suffer the consequences of poor care, becoming sterile or acquiring thrombosis that can lead to amputation of the legs. (PEREIRA, 2015).

Data about maternal mortality in Brazil
The Ministry of Health (2012)  Graph 1 shows that obstetric causes occupy the first place in the causes of maternal mortality, followed by direct causes and finally, indirect causes. These data refer to the period from 2001 to 2010. Pereira (2015) informs that the reduction of maternal mortality is one of the eight millennium goals signed by several countries and, among them, Brazil. In our country, the expectation is to reduce the rate to 35 deaths per 100,000 births. Gianini (2010) points out that the reference hospitals, for fulfilling a defined role in the care network for the care of more complex and serious cases, end up being sentinel sites for the occurrence of events of this nature, and can offer crucial data that contribute to solving the problem maternal mortality.
The WHO stresses that, in order to contribute to the reduction of maternal mortality, it is necessary to increase research that provides evidence-based clinical and programmatic guidance, establishing global standards and providing technical support to States. Knowing the urgency of this theme in Brazil, the possibility of using these correction factors to obtain more accurate estimates of how maternal mortality rates behave over the past few years is essential to know the regional differences and the main causes, as well as being extremely important for public health policies in the country and for planning the health service (SILVA et.al 2016).

METHODOLOGY
This is an exploratory descriptive study in which we chose methods of Integrative Literature Review (RIL), as it is a method that provides the synthesis of knowledge and the incorporation of applicability of results and significant studies in practice (Souza, Silva, Carvalho, 2010). In order to investigate the Maternal Mortality enabling an understanding of the factors that lead to this reality.
The search for scientific publications was carried out from April to August 2020, using virtual libraries: online electronic scientific library (SCIELO), Lilacs and Virtual Health Library, using the following descriptors "Pregnant Women", "Prenatal", "Incarcerated", "Prison". Regarding the eligibility criteria: articles published in the last 20 years 2002-2020 in Portuguese and Spanish complete and available for free.
Ineligibility criteria: articles in summary form, monographs, master's dissertation.
To achieve the objective, the following guiding question for the study was defined: What are the main factors that lead to Maternal Mortality?
From the answer to this question, we made the discussions, as established in the next paragraph of this work "results and discussion".

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After searching for articles through the scientific databases at the Virtual Health Library (VHL), Scielo, Lilacs and BVS, 20 studies were identified and after filtering and analysis, 15 were selected because they met the study inclusion criteria.
After detailed reading of each selected article, the data were crossed according to the objectives of the work.
In an analysis of maternal death estimates by Szwarcwald et.al (2014) in Brazil from 2009 to 2011, it was alarming in some states, especially in the State of São Paulo (Southeast Region) with more than 41 thousand maternal deaths of childbearing age.
The North Region had a result of more than 15 thousand deaths, being led by Pará State with 7,107 deaths followed by Amazonas with 3,219 deaths.

After Eligibility and Exclusion criteria
The following articles were selected to be included in the discussion

Totality: 20 Articles
In another study by Martins (2017) in the State of Minas Gerais, the characteristics of women who died due to abortion consequences were single, in a total of 117, (68%) aged between 24-34 years and 133, ( 72.7%) with schooling from 4th to 7th grade, total 36, (34.6%). Black women in a total of 105, (70.5%) and the most frequent place was in a hospital environment, 179, representing (97.8%).
In the study carried out by Gomes et.al (2018) in Bahia in the years 2004 to 2015 it was pointed out that the deaths occurred mostly with brown women (59.25%), aged between 20 and 29 years (39.12%). Regarding the level of education and marital status, the prevalence of single women (50.87%) and with schooling between 4th to 7th grade of elementary school (20.14%) was maintained. Penha et.al (2018) reports that in the years 2008 to 2010 he found 45 deaths due to direct obstetric causes, among them 50% were due to pre-eclampsia, eclampsia and hypertensive disease specific to pregnancy. Continuing the line of thought, the author claimed that hypertension is also the cause of premature births, since in this way it is possible to save the life of the mother and child.
Brito et.al (2015) points out that about 10% of pregnancies progress to high risk, of these, when SHEG (Specific Hypertensive Syndrome of Pregnancy) leads the ranking of causes of maternal mortality with fatality, with the highest rates present in the Northeast Regions and Midwest of Brazil.
The WHO cites some recommendations to prevent these cases from becoming irreversible and lethal, such as calcium supplementation for those with vitamin deficiency, regular monitoring of blood pressure and antihypertensive drugs for pregnant women with severe hypertension, in addition, it also recommends the use of low-dose acetylsalicylic acid for women who are at high risk of developing the problem in the future. In case of care during labor or delivery, the recommendation is to anticipate the induction of labor, the use of magnesium sulfate as an anti-inflammatory that can be administered intramuscularly or intravenously. Herculano et al (2012) mentions that in Brazil, despite advances in care for pregnant women at the outpatient (increased prenatal coverage and access to laboratory tests) and hospital (incentive to normal delivery, adoption of clinical protocols for management pathologies and complications), the actions developed have been shown to be less effective than desired in reducing maternal mortality. The main causes of maternal death continue to be hemorrhages and high blood pressure, both preventable through quality prenatal and childbirth care.
Regarding the cause of death from hemorrhage, Souza et.al (2013)  Thus, it was possible to notice that in addition to the research periods being the same, there was also a reduction in the numbers presented, however, the numbers are still not considered ideal and need more attention and care to avoid situations that may endanger mother and child throughout pregnancy.

CONCLUSION
The study on maternal mortality shows that the situation of pregnant women in Brazil is still worrying and needs to make society in general aware of the precarious and fragile situation faced by the female population.
In this sense, it is necessary to have health policies that include assistance to pregnant women, as well as their babies throughout pregnancy, especially prevention and care actions during the prenatal period.
This research, through the analysis of studies published recently, shows that Brazilian women, especially those in a vulnerable state, are in constant risk of being part of this maternal death statistic, because they do not have it often, not even within the family and not even on the part of the state psychological, maternal and prenatal care support, essential health services for a pregnant woman.
Thus, this study makes it possible to identify the profile of women who experience pregnancy at risk, as well as the way prenatal care is performed and their differences during childbirth. In view of what was exposed in the study, there is a need for systematic monitoring of women and their babies from basic health care, especially prenatal care accompanied by health professionals. Thus, it is expected that the work presented here will contribute to the reflection of health professionals and institutions in relation to pregnant women in a vulnerable state in Brazil. Prevalence of pregnancyspecific hypertensive syndromes (SHEG).

Portuguese/BVS
The provision of qualified care is an essential component for the early detection of complications, health education and, consequently, the reduction of maternal and fetal mortality.
Epidemiological profile of maternal deaths in Rio Grande do Sul, Brazil: 2004-2007 Portuguese/SCIELO It was observed that the highest RMME was found in women with less education.
HERCULANO, Marta Maria Soares et al (2012) Maternal deaths in a public maternity hospital in Fortaleza: an epidemiological study.
Portuguese/SCIELO Low quality of death investigation records was perceived, consequently, there may be higher numbers that aggravate this cause.