By Ana Maria Costa and Luís Bernardo Delgado Bieber**
On May 31st, 2012, the deadline for the Provisional Measure number 557 (MP 557) to be voted by the Congress expired.*** Edited in December 26th, 2011 the MP 557 was published the following day. It created the National System of Registration, Tracking and Follow-up of Pregnant and Puerperal Women for the Prevention of Maternal Mortality and authorized the Federal government to grant financial benefits to poor pregnant women and modified the Law No. 8080 from September 19th, 1990 (the Organic Law of Health). The MP has also modified e Law No. 9782, from January 26th, 1999, which established the National Sanitary Surveillance System and created the National Agency of Sanitary Surveillance.
Published in the midst of a Christmas holiday – a period when no great social mobilization is expected to happen — the Provisional Measure was received with sharp critique by civil society organizations, especially the women’s movement. Their criticisms were as follows: the content of the MP had not been previously discussed with civil society actors; the MP established a compulsory registration of pregnant women, which potentially implied the surveillance of women’s reproductive life; the text included language on the right of the unborn to health care. It should be noted that the Brazilian constitution does not include right to life since conception and that in other national the right of the unborn is exceptionally considered in the case of inheritance rights. The inclusion in the MP of the right to safety and humane cares to both the mother and the unborn in prenatal, childbirth, birth and postpartum care was therefore unconstitutional and at odds with the content of Law. 8.080/90, known as the Organic Health Law, which does not include such provisions.
The critiques of the MP 557 were many and expressive. A month later, on January 27th, 2012 — under the justification of that a “rectification” was required, a procedure that is very unusual in the case of this type of legal document – the Executive branch re-published he text. The “rectified” version, excluded the main aspect criticized by the feminist movement: the rights of unborn to health care but left intact other problematic aspects. From the point of view of the legislative process the “rectification” implied that the processing of the decree by Congress started all over again. But even when the time frame for processing MP 557 has been extended by a month and tone key problem identified by critique of civil society actors has been removed no consensus was reached at the House on the text, which lost its validity before being voted and sent to the Senate. Fortunately, after three months of pressures and bargains, the MP 557 has been sent to the archives. It must noted, however, that the Ministry of Health has issued an ordinance regulating the granting of financial benefits to pregnant women (through the ordinance GM / MS No. 68 of January, 11th 2012), even before the measure had been approved by the House.
The Brazilian Center for Health Studies (CEBES) positioned itself against the approval of the MP 557 in line, among other, with the National Health Council – which the highest accountability mechanism of the public health system –, feminists voices and the Brazilian Association of Collective Health (ABRASCO). We did so because, in our evaluation, the mechanism proposed by MP 557 was a vertical and isolated measure that would fragment the structure of women health care, in a manner inconsistent with the long standing perspective of comprehensiveness that has guided Brazilian women’s health policies since its inception in the 1980’s. Many members of the Brazilian Parliament contributed to the strengthening of the opposition and mobilization against the MP 557. The decree did not managed to get support beyond the Ministry of Health itself and the “evangelic group” at Congress.
Brazilian public health organizations, particularly CEBES and ABRASCO, consider that the compulsory register of all pregnant women and financial assistance to cover the cost of transportation to health services, which are the main points of the Provisional Measure, would not have an automatic potential impact on indicators of maternal and infant mortality. In fact, in the view of CEBES, the MP raised unjustified expectations of positive outcomes that merely postponed the effective addressing of factors determining pregnancy related deaths in Brazil. The registration of pregnant women is totally unnecessary because the information currently available is sufficient to fully detect the causes of maternal deaths and consistently define national and local strategies to change this tragic reality. Furthermore the format adopted by the surveillance system proposed by the MP potentially exposed women and their reproductive lives and decisions in a society that today is highly polarized in relation to moral visions on sexual and reproductive rights.
The MP 557 opened the possibility for women — who eventually chose to termination and unwanted pregnancy to be identified and criminally indicted — in a context where the presence of anti- abortion groups and actors in very strong in financial and political terms and these voices are present at Congress and also at the Executive branch. It is not possible for a new Provisional Measure to be presented on this topic in this legislature the matter is not be considered fully resolved. Risks have not been, however, overcome. In particular, because 2012 is once again an electoral year and, as we do know, during elections negotiations are often made in which abortion is easily bargained in exchange for the political support from conservative sectors in society.
The many caveats of MP 557
• The Provisional Measure 557 (MP 557) did not addressed unsafe abortion that is one of the main causes of maternal mortality in Brazil.
• The MP 557 addressed the maternal and child mortality as if these are problems exclusively deriving from lack of access to health services. This is made evident by the fact that it established a financial benefit of 25 dollars to cover the transportation costs poor pregnant women incur to reach basic health care and hospitals. However, access to services is not a problem in Brazil. The number of prenatal appointments corresponds to what is recommended by the World Health Organization. The key problem experienced by Brazilian pregnant women is the bad quality of the prenatal and obstetric care.
• Furthermore, if the problem of access to health services was, in fact, one factor explaining maternal and child mortality indicator, this must be resolved by the re-organization of the public health system local networks and not through a personal cash transfer. It is the responsibility of the public health system to identify and search for “missing pregnant women” that may be having difficulties to get to services. The MP conceives the health system merely as the structures in which service is provided, limits the state responsibility for pregnant women’s health and transfer this to women themselves, who are now supposed to reach out the system because they have been granted 25 US $.
• Independently of the perspective used to analyze the “transportation cash transfer” in our view this benefit is distorted and authoritarian. It symbolically links the responsibility for the high rates of the maternal mortality to the individual condition and behavior of women themselves, when, in reality, women who experience problems or die during pregnancy are victimized by unequal socioeconomics conditions and the bad quality of care provided by health systems.
• The main problem of prenatal assistance and childbirth services in Brazil is the quality of the care. This situation is paradoxical because, on the one hand, maternal health care is characterized by the excessive and unjustified use of sophisticated medical procedures and interventions even in the case of low risk pregnancies, as illustrated by the alarming rate of cesarean sections, which also contribute to maternal mortality levels. On the other, the public system is organized in such ways that technology and more complex interventions may not be provided exactly when they are needed.
• The definitions regarding “risk pregnancy” and “risk factors” must go beyond factors affecting individual women as to address structural determinants of health problems and outcomes. Data shows that maternal mortality is higher among black women and important regional disparities also exist. Both these structural determinants and individual risk factors must be consistently tackled for maternal mortality rates to be effectively reduced in n Brazil.
*Published, on June, 6th, 2012 at:
** Ana Maria Costa, President of CEBES is a medical doctor and a public health expert
Luís Bernardo Delgado Bieber, Executive Director of CEBES is a lawyer who works at the National Agency of Surveillance – ANVISA
*** A Provisional Measure is an instrument issued by the Executive branch to speed up the legislative process. It is a decree signed by the President of the Republic sent to Congress that must be processed in 120 days (four months), otherwise it is filed. However, even before being fully approved a Provisional Measure has the force of law as it allows the Executive to implement actions being proposed. The Constitution defines that MP must not be used systematically, but juts in urgent or emergency situations. But the reality is that since 1988, MPs have been abusively utilized by the Executive Branch and are usually resisted by the two houses.