Brazil’s most vulnerable are struggling to survive the stress of covid

When oxygen supplies ran out in several municipalities across the Brazilian state of Amazonas in January, 61 premature babies grabbed the headlines.

The tiny infants didn't have covid-19, but the Amazonas State Secretariat of Health (SES-AM) was worried that the strain the pandemic was putting on the health-care system had left them in danger.

Things were already precarious: according to the local news site Amazonia Real, doctors at one maternity ward in the capital city of Manaus were left to provide manual ventilation for 10 babies, pumping bags with their hands for hours to keep them alive.

It was a moment of sheer panic. Families, friends, and volunteers scoured the city for any remaining oxygen; some sent cylinders from other parts of the country. Meanwhile, the governments of other states offered to make room for the babies in their neonatal intensive care units (NICUs).

Eventually, after confirming that there was enough oxygen to keep the preemies breathing for at least 48 hours, officials let them stay where they were. But by that time the crisis had made it clear that some of the country's most vulnerable patients were being heavily affected by the pandemic, even if they didn't actually have covid-19. And it was soon obvious that more widespread trouble for premature babies had already been brewing.

Left floundering

Ever since the coronavirus started to swallow up Brazil in early 2020, preterm births had been on the rise-in part because for some pregnant women who contracted the disease, early delivery through C-sections or induced labor was necessary to keep them and their babies breathing. Today Brazil has the world's second-highest number of covid-19 deaths, at more than 500,000, and still struggles to keep the disease and its collateral damage at bay. Experts aren't hopeful the situation will improve anytime soon.

Some of that damage is related to the country's politics. Brazil's president, Jair Bolsonaro, has consistently referred to it as a little flu," and despite having caught the disease himself, he has downplayed the severity of covid-19 while promoting medications like hydroxychloroquine as a treatment long after it was proved ineffective (and sometimes dangerous) in patients with the virus.

His denialism has left medical professionals without support, floundering to care for patients without the proper resources for either prevention or treatment. Brazil has seen more than 16.7 million cases throughout the pandemic, and the daily death rate currently sits at roughly 2,000. Although that's down from daily highs of 4,000 in April's second wave, it's still one of the highest in the world.

While quality and availability of health care can vary across a country as large as Brazil, even the country's best medical facilities have been brought to the brink of collapse, and only well-off areas such as Sao Paulo have seen any rebound.

And six months on from the oxygen crisis in Amazonas, mothers and babies are still feeling the effects.

Care complications

Each year, around 340,000 babies in Brazil are born prematurely-before 37 weeks. That's double the rate for Europe and, according to the World Health Organization (WHO), the 10th-highest number of preterm births in the world. Many crucial methods of care for these babies, including early breastfeeding and skin-to-skin contact with their parents, remain on hold at hospitals around the country despite evidence that this puts their growth, development, and even survival at much higher risk than covid-19.

While the number of preterm births in Brazil for 2020 has yet to be released, experts such as Denise Suguitani-founder and director of nonprofit Prematuridade, the only national NGO in the country to support premature babies and their families-suspect there will be an increase over previous years.

Prenatal care could prevent many mothers from delivering prematurely, but covid-19 has made expectant parents much more likely to skip those doctor's visits. According to a study conducted by the Brazilian Federation of Gynecology and Obstetrics Associations in July and August of last year, 81% of obstetrician/gynecologists consulted said their patients were worried about contracting covid-19 during prenatal appointments.

When the mom has covid and ends up with breathing problems, the baby could go into asphyxia in utero."

Rossiclei Pinheiro, Federal University of Amazonas

It's during prenatal appointments that risks of premature births are identified," Suguitani says. So if a pregnant woman skips an appointment or an exam, there's a possibility that a problem in her pregnancy that could lead to a preterm birth will go undetected."

Contracting covid-19 during pregnancy can also be a factor in preterm births. According to Rossiclei Pinheiro, a pediatrician and neonatologist at the Federal University of Amazonas, early labor can start when the inflammatory reaction brought on by the coronavirus-or any other type of infection-manifests itself in the amniotic membrane, causing it to rupture prematurely.

In other cases, babies whose mothers have covid-19 have had to be delivered early on purpose.

When the mom has covid and ends up with breathing problems, the baby could go into asphyxia in utero," Pinheiro says.

The dangers of limiting contact

During the pandemic, hospitals have limited NICU visitors, and some staff have even stopped parents from touching their babies. Pinheiro and other experts say this is the wrong approach.

A particularly important form of skin-to-skin contact involves newborns resting chest-to-chest on top of a parent. It's called kangaroo care, and it has been shown to reduce infant deaths by 40%, hypothermia by more than 70%, and severe infections by 65%. In a March study, WHO and partner researchers found that kangaroo care made babies born to covid-infected mothers far more likely to survive, and the benefits far outweighed the small risk of dying from the virus.

Carla Luana da Silva, a 27-year-old woman from the state of Sao Paulo, was not just prevented from practicing kangaroo care with her extremely premature baby-she was blocked from having any contact with her whatsoever. Da Silva says it was one of the hardest parts of the baby's 81-day stay in the NICU.

Maria Vitoria weighed less than two pounds when she was born at 26 weeks-a surprise even to the staff at the hospital in the city of Presidente Prudente. The infant was whisked to the NICU, where she was intubated and hooked up to machines to help her breathe. She needed blood transfusions and antibiotics pumped into her tiny veins to keep her alive.

When nobody was looking, da Silva would open the incubator door and place the tip of her finger in the palm of her daughter's hand. But the nurses caught her; she was chastised and told she couldn't touch her baby because of covid."

Prematuridade, the NGO run by Suguitani, has been acting as a go-between during the pandemic, speaking to hospital staff and administrators on behalf of families in an attempt to help these babies thrive.

It also wants hospitals to allow mothers to breastfeed even if they have covid-19.

Breast milk is the best source of nutrition for newborns, providing protection against numerous diseases," says Edna Maria de Albuquerque Diniz, a pediatrician and neonatologist at the University of Sao Paulo's Hospital das Clinicas. So the recommendation of several international and national entities is that postpartum women in good general condition should continue to breastfeed, wearing protective masks and washing their hands before and after."

If a mother is unable to breastfeed directly, both Diniz and Pinheiro say, her milk should still be given to her baby, as it will contain antibodies that could help protect the infant from covid-19.

But one of the most important ways to protect babies, Pinheiro says, is to take care of their mothers. Brazil has given out 88 million doses of vaccines for its population of 214 million, but pregnant and postpartum women weren't originally considered priority vaccination groups. In fact, most pregnant women were blocked from vaccination when a 35-year-old pregnant woman in Rio de Janeiro died after receiving the AstraZeneca vaccine. Now, only those pregnant and postpartum women with comorbidities can be vaccinated, and only with the other vaccines available in Brazil: those from Sinovac and Pfizer. The Federal Prosecutor's Office has recently demanded that pregnant and postpartum women without comorbidities be made eligible for vaccination again.

Experts say that access to vaccines and prenatal care is crucial to keeping both mothers and babies healthy-especially because Brazil's fight with the coronavirus doesn't seem likely to be slowing down anytime soon. President Bolsonaro continues to attend large events without wearing a mask and has told the public to stop whining." He is now being investigated in a parliamentary inquiry for his administration's failures in handling the pandemic, including the slow start acquiring vaccines and the lack of oxygen in Manaus that panicked doctors caring for premature babies; that crisis also left 31 adults dead. Large street protests calling for his impeachment have taken place across the country, and more are expected soon.

A lot of women have died and babies have been left without their moms, or even without their parents," Pinheiro says. That's why we need to protect pregnant women. They're going to have their babies, and they need to be there for them. They need to take care of them."

This story is part of the Pandemic Technology Project, supported by the Rockefeller Foundation.