{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T05:59:56Z","timestamp":1780639196784,"version":"3.54.1"},"reference-count":42,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T00:00:00Z","timestamp":1779926400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nursing Reports"],"abstract":"<jats:p>Background\/Objectives: Maternal mortality remains an important indicator of health inequities, reflecting social, regional, and racial inequalities, as well as the responsiveness of health systems. This study aimed to analyze and compare maternal mortality between Brazil and Portugal from 2020 to 2023. Methods: This is a binational ecological and observational study based on secondary data from official records of live births and maternal deaths in both countries. Maternal mortality rates were calculated per 100,000 live births and stratified by sociodemographic and regional variables. Poisson regression models offset by the logarithm of live births were used to estimate adjusted incidence ratios (IRR) and 95% confidence intervals. Analyses were conducted using R and Stata software. Results: Brazil presented rates between 55 and 62 per 100,000 live births, while Portugal maintained lower values, ranging from 8 to 20 per 100,000. In Brazil, higher risks were observed among Black and Indigenous women, residents of the North and Northeast regions, and in age groups above 30 years. Direct and indirect causes showed similar proportions, with an increase in indirect causes during the pandemic. In Portugal, mortality showed low magnitude, but annual fluctuation was attributed to the small number of events and the limitation of microdata. Conclusions: The study highlights strong structural and racial inequalities in Brazilian maternal mortality, contrasting with the lower magnitude and greater stability observed in Portugal. This reinforces the need for intersectoral actions, strengthening the obstetric network, and continuous surveillance to reduce preventable deaths and promote equity in maternal care.<\/jats:p>","DOI":"10.3390\/nursrep16060185","type":"journal-article","created":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T10:06:56Z","timestamp":1780049216000},"page":"185","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Binational Analysis of Maternal Mortality Between Brazil and Portugal in 2020\u20132023: A Population-Based Epidemiological Study"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1615-7646","authenticated-orcid":false,"given":"Gustavo","family":"Gon\u00e7alves dos Santos","sequence":"first","affiliation":[{"name":"Programa de P\u00f3s-Gradua\u00e7\u00e3o em Enfermagem, Universidade Guarulhos (UnG), Guarulhos 07023-070, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0548-8829","authenticated-orcid":false,"given":"M\u00f3nica Alexandra Pinho da","family":"Silva","sequence":"additional","affiliation":[{"name":"Escola Superior de Enfermagem do Porto, Universidade do Porto (ESEP\/UP), 4200-072 Porto, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2510-5955","authenticated-orcid":false,"given":"Maria Jo\u00e3o Jacinto","family":"Guerra","sequence":"additional","affiliation":[{"name":"Escola Superior de Enfermagem do Porto, Universidade do Porto (ESEP\/UP), 4200-072 Porto, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4893-7690","authenticated-orcid":false,"given":"J\u00falia Maria","family":"das Neves Carvalho","sequence":"additional","affiliation":[{"name":"Escola Superior de Enfermagem de Coimbra, Universidade de Coimbra (ESEnfC\/UC), 3046-851 Coimbra, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana Cristina Ribeiro","family":"da Fonseca Dias","sequence":"additional","affiliation":[{"name":"Escola Superior de Sa\u00fade, Universidade dos A\u00e7ores (UAc\/ESS), 9500-315 Ponta Delgada, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1274-7473","authenticated-orcid":false,"given":"Maria Lu\u00edsa Santos","family":"Bettencourt","sequence":"additional","affiliation":[{"name":"Escola Superior de Sa\u00fade, Universidade dos A\u00e7ores (UAc\/ESS), 9500-315 Ponta Delgada, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3407-799X","authenticated-orcid":false,"given":"Cely de","family":"Oliveira","sequence":"additional","affiliation":[{"name":"Universidade Santa Cec\u00edlia (UNISANTA), Santos 11045-907, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruna","family":"Feichas Ren\u00f3","sequence":"additional","affiliation":[{"name":"Universidade Santa Cec\u00edlia (UNISANTA), Santos 11045-907, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eneida","family":"Tramontina Cerqueira","sequence":"additional","affiliation":[{"name":"Universidade Santa Cec\u00edlia (UNISANTA), Santos 11045-907, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katucha","family":"Rocha de Almeida Farias","sequence":"additional","affiliation":[{"name":"Universidade Cat\u00f3lica de Santos (UNISANTOS), Santos 11070-906, SP, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"25","DOI":"10.11606\/s1518-8787.2024058005862","article-title":"Racial disparities and maternal mortality in Brazil: Findings from a national database","volume":"58","author":"Silva","year":"2024","journal-title":"Rev. Saude Publica"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"23960","DOI":"10.1038\/s41598-024-74704-x","article-title":"Time series analysis of comprehensive maternal deaths in Brazil during the COVID-19 pandemic","volume":"14","author":"Cambou","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_3","first-page":"100774","article-title":"Maternal and perinatal health indicators in Brazil over a decade: Assessing the impact of the COVID-19 pandemic and SARS-CoV-2 vaccination through interrupted time series analysis","volume":"35","author":"Costa","year":"2024","journal-title":"Lancet Reg. Health Am."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Ferreira, N., Ferreira, M., Santos, E., Ferreira, S., de Arriaga, M.T., and Costa, A. (2025). Health literacy and its determinants among pregnant women in Portugal. BMC Public Health, 25.","DOI":"10.1186\/s12889-025-24225-7"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Tavares, M., Alexandre-Sousa, P., Vict\u00f3ria, A., Loureiro, S., Santos, A.P., and Mendes, J. (2024). Experience of Labour and Childbirth in a Sample of Portuguese Women: A Cross-Sectional Study. Healthcare, 12.","DOI":"10.3390\/healthcare12212125"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e85","DOI":"10.3346\/jkms.2025.40.e85","article-title":"Global, Regional, and National Trends in Maternal Mortality Ratio Across 37 High Income Countries from 1990 to 2021, with Projections up to 2050: A Comprehensive Analysis from the WHO Mortality Database","volume":"40","author":"Lee","year":"2025","journal-title":"J. Korean Med. Sci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"460.e1","DOI":"10.1016\/j.ajog.2024.02.008","article-title":"Maternal vaccination against COVID-19 and neonatal outcomes during Omicron: INTERCOVID-2022 study","volume":"231","author":"Barros","year":"2024","journal-title":"Am. J. Obs. Gynecol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1055\/s-0043-1768456","article-title":"Age and Type of Delivery as Risk Indicators for Maternal Mortality","volume":"45","author":"Oliveira","year":"2023","journal-title":"Rev. Bras. Ginecol. Obstet."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies","volume":"61","author":"Altman","year":"2008","journal-title":"J. Clin. Epidemiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e626","DOI":"10.1016\/S2214-109X(24)00560-6","article-title":"Global and regional causes of maternal deaths 2009-20: A WHO systematic analysis","volume":"13","author":"Cresswell","year":"2025","journal-title":"Lancet Glob. Health"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1S","DOI":"10.1097\/AOG.0000000000006264.03","article-title":"National Trends in Maternal Mortality from Obstetric Causes in the United States, 2007\u20132023 [ID 2335]","volume":"147","author":"Byun","year":"2026","journal-title":"Obstet. Gynecol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"103505","DOI":"10.1016\/j.eclinm.2025.103505","article-title":"Assessing differences in country-level estimates of maternal mortality: A comparison of GMatH, UN, and GBD model results for 2020","volume":"88","author":"Ward","year":"2025","journal-title":"EClinicalMedicine"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e306","DOI":"10.1016\/S2214-109X(23)00468-0","article-title":"A global analysis of the determinants of maternal health and transitions in maternal mortality","volume":"12","author":"Souza","year":"2024","journal-title":"Lancet Glob. Health"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Orellana, J.D.Y., Leventhal, D.G.P., Flores-Quispe, M.D.P., Marrero, L., Jacques, N., Mor\u00f3n-Duarte, L.S., and Boschi-Pinto, C. (2024). Impact of the COVID-19 pandemic on excess maternal deaths in Brazil: A two-year assessment. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0298822"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1002\/ijgo.13726","article-title":"Maternal death related to COVID-19: A systematic review and meta-analysis focused on maternal co-morbidities and clinical characteristics","volume":"154","author":"Riemma","year":"2021","journal-title":"Int. J. Gynaecol. Obstet."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Ca\u00f1edo, M.C., Lopes, T.I.B., Rossato, L., Nunes, I.B., Faccin, I.D., Salom\u00e9, T.M., and Simionatto, S. (2024). Impact of COVID-19 pandemic in the Brazilian maternal mortality ratio: A comparative analysis of Neural Networks Autoregression, Holt-Winters exponential smoothing, and Autoregressive Integrated Moving Average models. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0296064"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1055\/s-0042-1748975","article-title":"Maternal Deaths from COVID-19 in Brazil: Increase during the Second Wave of the Pandemic","volume":"44","author":"Scheler","year":"2022","journal-title":"Rev. Bras. Ginecol. Obs."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Kassa, Z.Y., Scarf, V., Turkmani, S., and Fox, D. (2024). Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review. Int. J. Environ. Res. Public Health, 21.","DOI":"10.3390\/ijerph21091188"},{"key":"ref_19","first-page":"100239","article-title":"Maternal mortality and the lack of women-centered care in Brazil during COVID-19: Preliminary findings of a qualitative study","volume":"10","author":"Diniz","year":"2022","journal-title":"Lancet Reg. Health Am."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3658","DOI":"10.1007\/s40615-023-01816-x","article-title":"The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature","volume":"11","author":"Montalmant","year":"2024","journal-title":"J. Racial Ethn. Health Disparities"},{"key":"ref_21","first-page":"e09952023","article-title":"Obstetric racism, a debate under construction in Brazil: Perceptions of black women on obstetric violence","volume":"29","author":"Santana","year":"2024","journal-title":"Cien. Saude Colet."},{"key":"ref_22","first-page":"101183","article-title":"Mortality trends among Indigenous women of reproductive age in Brazil: A time series analysis","volume":"48","author":"Ferreira","year":"2025","journal-title":"Lancet Reg. Health Am."},{"key":"ref_23","first-page":"100343","article-title":"High maternal mortality rates in Brazil: Inequalities and the struggle for justice","volume":"14","author":"Tenorio","year":"2022","journal-title":"Lancet Reg. Health Am."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"102923","DOI":"10.1016\/j.healthplace.2022.102923","article-title":"Structural racism and adverse maternal health outcomes: A systematic review","volume":"78","author":"Hailu","year":"2022","journal-title":"Health Place"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"12918","DOI":"10.1038\/s41598-023-40150-4","article-title":"High maternal mortality rate associated with advanced maternal age in Japan","volume":"13","author":"Tanaka","year":"2023","journal-title":"Sci. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Hochler, H., Lipschuetz, M., Suissa-Cohen, Y., Weiss, A., Sela, H.Y., Yagel, S., Rosenbloom, J.I., Grisaru-Granovsky, S., and Rottenstreich, M. (2023). The Impact of Advanced Maternal Age on Pregnancy Outcomes: A Retrospective Multicenter Study. J. Clin. Med., 12.","DOI":"10.3390\/jcm12175696"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Nyongesa, P., Ekhaguere, O.A., Marete, I., Tenge, C., Kemoi, M., Bann, C.M., Bucher, S.L., Patel, A.B., Hibberd, P.L., and Naqvi, F. (2023). Maternal age extremes and adverse pregnancy outcomes in low-resourced settings. Front. Glob. Womens Health, 4.","DOI":"10.3389\/fgwh.2023.1201037"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Pinho Neto, V., Machado, C., Lima, F., Roman, S., and Dutra, G. (2024). Inequalities in the geographic access to delivery services in Brazil. BMC Health Serv. Res., 24.","DOI":"10.1186\/s12913-024-12042-4"},{"key":"ref_29","first-page":"100976","article-title":"Geographic accessibility to hospital childbirths in Brazil (2010\u20132011 and 2018\u20132019): A cross-sectional study","volume":"42","author":"Albuquerque","year":"2025","journal-title":"Lancet Reg. Health Am."},{"key":"ref_30","first-page":"e240009","article-title":"Maternal health surveillance panel: A tool for expanding epidemiological surveillance of women\u2019s health and its determinants","volume":"27","author":"Domingues","year":"2024","journal-title":"Rev. Bras. Epidemiol."},{"key":"ref_31","first-page":"e230007","article-title":"Usefulness of the Hospital Information System for maternal mortality surveillance in Brazil","volume":"26","author":"Ranzani","year":"2023","journal-title":"Rev. Bras. Epidemiol."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Alipour, J., Payandeh, A., and Karimi, A. (2023). Prevalence of maternal mortality causes based on ICD-MM: A systematic review and meta-analysis. BMC Pregnancy Childbirth, 23.","DOI":"10.1186\/s12884-023-06142-y"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1111\/1471-0528.18342","article-title":"Variability in the Causes and Delay Factors Contributing to Maternal Mortality: Evidence from Maternal Death Surveillance Reports of 22 African Countries","volume":"133","author":"Muriithi","year":"2025","journal-title":"BJOG"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"5783","DOI":"10.1097\/JS9.0000000000002979","article-title":"Long-term dynamic burden and attributable risk analysis of indirect maternal mortality over the past 30 years: An observational study and insights for perioperative management in the next decade","volume":"111","author":"Jiang","year":"2025","journal-title":"Int. J. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1111\/ppe.70034","article-title":"Temporal Changes in the Contribution of Chronic Disease to Maternal Mortality in the United States","volume":"39","author":"Sabr","year":"2025","journal-title":"Paediatr. Perinat. Epidemiol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Wu, N., Ye, E., Ba, Y., Caikai, S., Ba, B., Li, L., and Zhu, Q. (2024). The global burden of maternal disorders attributable to iron deficiency related sub-disorders in 204 countries and territories: An analysis for the Global Burden of Disease study. Front. Public Health, 12.","DOI":"10.3389\/fpubh.2024.1406549"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e00542","DOI":"10.1016\/j.crwh.2023.e00542","article-title":"Reducing maternal mortality in low- and middle-income countries","volume":"39","author":"Ekwuazi","year":"2023","journal-title":"Case Rep. Womens Health"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1975","DOI":"10.3109\/14767058.2012.668587","article-title":"How many maternal deaths are there in Portugal?","volume":"25","author":"Gomes","year":"2012","journal-title":"J. Matern. Fetal Neonatal Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"880","DOI":"10.1111\/j.1471-0528.2012.03330.x","article-title":"What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe","volume":"119","author":"Mohangoo","year":"2012","journal-title":"BJOG"},{"key":"ref_40","first-page":"e4668","article-title":"Analysis of the influence of the COVID-19 pandemic on maternal mortality trends, 2011\u20132021","volume":"33","author":"Peppe","year":"2025","journal-title":"Rev. Lat. Am. Enferm."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Brezeanu, A.-M., Brezeanu, D., and Tica, V.-I. (2025). Intraoperative Platelet-Rich Plasma (PRP) for Post-Cesarean Scar Healing: A Single-Center Randomized Controlled Pilot Study. Healthcare, 13.","DOI":"10.3390\/healthcare13222928"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Brezeanu, D., Brezeanu, A.-M., and Tica, V. (2026). Lactic Acid-Loaded Hydrogels for Post-Episiotomy Wound Healing: Microenvironment Engineering and Regenerative Strategies\u2014A Narrative Review. Molecules, 31.","DOI":"10.3390\/molecules31071094"}],"container-title":["Nursing Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-4403\/16\/6\/185\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T05:03:17Z","timestamp":1780635797000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-4403\/16\/6\/185"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,28]]},"references-count":42,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["nursrep16060185"],"URL":"https:\/\/doi.org\/10.3390\/nursrep16060185","relation":{},"ISSN":["2039-4403"],"issn-type":[{"value":"2039-4403","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,28]]}}}