Maternal Mortality Among Black Women in Brazil: A Retrospective Cohort Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this work. The authors have aimed to determine the sociodemographic, clinical and contextual factors associated with the increased risk of maternal mortality among black women in Brazil between 2000 and 2023. The findings suggested that maternal mortality was high among black women in Brazil and the maternal mortality ratio was higher among Black compared to White women and even higher among indigenous women.

Overall, interesting work and looking into the factors which increase the risk of maternal mortality especially among Black women is of high importance. The authors need to address the comments below to improve overall readability of the manuscript.

Comments:

• Please reduce the length of the introduction. It is currently too long and includes a lot of background information. Please consider condensing the length and keep it more focused. There is a lot of data on maternal mortality in the United States and this information can be reduced. Are there data available on maternal mortality in Brazil? If so, please add some of that information in the introduction.
• Lines 125 and 154: are these data based for population in the United States?
• Why was the study timeline selected between 2000-2023?
• Table 3: the second part of the table includes education, region, direct, indirect etc. It is very difficult to interpret this table especially because above this the numbers represented rates, RR and CIs. Please clarify this table by including proper footnotes explaining what these numbers represent. It might be better to make this a separate table to improve clarity.
• Please make this change throughout the manuscript: instead of decimals, there are commas with all the number which should have had a decimal.
• Please add footnotes to all tables to improve clarity

 

Author Response

Dear Reviewer,

We sincerely thank you for your careful reading of our manuscript and for the valuable observations and suggestions you provided, which significantly contributed to improving the clarity and quality of the work. Below, we present detailed responses to each of your comments, as well as the corresponding modifications made to the text.

1) The introduction has been substantially reduced and restructured to make it more concise and objective. Information on maternal mortality in the United States has been summarized, and we have included updated data on maternal mortality in Brazil, as suggested.

2) Regarding lines 125 and 154, we confirm that the data refers to the population of the United States, and this information was duly specified in the text.

3) The period from 2000 to 2023 was selected because it encompasses a broad and up-to-date time series, allowing for the analysis of long-term trends, as well as including the period before and after the COVID-19 pandemic. This justification is included in the Methods section.

4) Thank you for your insightful suggestion to improve clarity and readability. Table 3 has been divided into two independent tables, and we have added detailed footnotes explaining the meaning of the values ​​presented.

5) We reviewed the entire manuscript and replaced the commas with decimal points in all numerical values, adapting the format to international standards.

6) As recommended, all tables were reviewed and received explanatory footnotes regarding variables, abbreviations, and types of values ​​presented.

Once again, we thank you for your constructive feedback. We believe the modifications made have significantly contributed to the scientific improvement and clarity of the manuscript. Thank you.

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting study. But it can be improved while focusing on the following aspects: 

1. It should benefit from the theoretical framework of syndemics as the study situates maternal morality at the intersection of several sociocultural, economic determinants i.e., "racial, social and territorial inequalities". With this theory, the results and discussion will be more rigorus and strengthened. 

   Specifically, syndemics theory enables a nuanced analysis of how these interacting factors amplify health inequities, offering a more robust interpretation of the study’s findings. So you are suggested to refer to the relevant literature. 

2. Some terminology also needs to be revisited such as "black" and "brown". Such terms have been criticized due to their preloaded and biased meanings. 
3. Based on these suggestions, the conclusion section will need substantial revisions. 

Author Response

Dear reviewer,

Thank you for your insightful observations and valuable recommendations, which significantly contributed to the theoretical and conceptual improvement of the manuscript. Our detailed responses are presented below:

1) We are immensely grateful for this theoretical suggestion, considered extremely relevant to the object of study. The manuscript was revised, and the theoretical framework of syndemics was incorporated into both the Introduction and the Discussion, highlighting the interrelationship between social, racial, and territorial determinants and their synergistic effects on maternal mortality. Updated references addressing syndemic theory and its application to public health were included, strengthening the conceptual basis and the interpretation of the results.

2) Thank you for your insightful and relevant observation. We have revised the terminology used in the manuscript, adapting it to the official nomenclature adopted by the Brazilian Institute of Geography and Statistics (IBGE) and to current ethical and academic recommendations. The text now presents the classification "color/race" according to the standard used in official Brazilian databases, ensuring conceptual accuracy and respect for diversity.

3) The Conclusion section has been extensively revised to incorporate the theoretical perspective of syndemics and reflect enhanced discussions on observed structural inequalities. The new wording emphasizes the interaction between social, racial, and territorial factors and their implications for public maternal health policies.

We thank you again for your constructive observations, which contributed significantly to strengthening the theoretical, methodological, and ethical aspects of the manuscript. Thank you.

Reviewer 3 Report

Comments and Suggestions for Authors

The article addresses a highly relevant topic, with clear scientific significance and strong interest for the design and implementation of public policies, particularly concerning an avoidable phenomenon such as maternal mortality. It presents a consistent theoretical framework, although focused mainly on the U.S. context. The concepts discussed, including that of intersectionality, are pertinent.

The objectives are clearly defined and appropriate to the topic under study. The study design is well framed and justified in terms of usefulness and scope, with the criteria for case selection and corresponding analysis clearly identified. The variables and their respective categories are detailed thoroughly. The type of empirical analysis and the results are presented with rigor and precision.

In this sense, the article appears relevant, consistent, and worthy of publication.

However, I believe it could benefit from some improvements, which I outline below:

1. Introduction: The introduction lacks contextual information about the country, particularly regarding recent public policy developments and the functioning of the public health system, including data on the characteristics of childbirth (type of health facility, mode of delivery, and professionals attending births). This information would strengthen the discussion.
2. Methodology and Results: It is not clear how the concept of racism is measured, nor how the authors justify conclusions related to obstetric racism, given that the type of analysis employed does not seem best suited to such an interpretation.
3. Variable “Skin Color”: There is no critical reflection on the categories used for the variable skin color and its centrality to the study, in relation to other variables or to potential complementary approaches.
4. Analytical Framework: The authors also do not fully address, in the theoretical framework, all variables later considered in the analysis (such as region, which becomes relevant in the results).
5. Discussion: In the discussion section, considering the study’s theme, the authors could include a reflection on possible measures to support affected families—for instance, the inclusion of emotional support mechanisms for families experiencing recent bereavement.

Thank you very much.

Author Response

Dear reviewer,

Thank you for your detailed observations and extremely pertinent suggestions, which contributed to the theoretical, methodological, and analytical improvement of the manuscript. Below, we present the responses to each comment, along with the respective modifications made to the text:

1) The introduction has been revised and expanded to include contextual information about the Brazilian Unified Health System (SUS), public policies focused on maternal health, and recent data on the characteristics of childbirth in Brazil (type of delivery, type of facility, and professionals involved in care). This expansion offers a more complete overview of the Brazilian reality and provides a more solid foundation for the discussion of the results.

2) In the Methods section, we included a detailed explanation that the study does not directly measure racism, but considers it as an interpretative category in the analysis of maternal mortality differentials according to race, drawing on literature that discusses structural and institutional racism as social determinants of health. In the Discussion, we revised the text to make it clear that the conclusions do not interpret direct causality, but rather inequalities that can be understood in light of structural racism.

3) We included a critical reflection in the Discussion, addressing the limitations and implications of using the variable "skin color," according to the official IBGE classification, as well as its centrality in the context of racial inequalities in health. We also added a paragraph highlighting the importance of complementary approaches, such as social class, education, and geographic region, which interact with race in determining maternal inequalities.

4) We revised the theoretical and methodological framework to include the geographic region variable and other contextual dimensions that proved relevant to the analysis. This inclusion allowed for a better alignment of the analytical model with the theoretical discussion and improved coherence between the sections of the manuscript.

5) The discussion was expanded with the inclusion of a paragraph proposing psychosocial and emotional support actions for families experiencing maternal grief, based on public policies and existing support experiences within the Brazilian Unified Health System (SUS). This addition reinforces the applied and humanized nature of the study.

Once again, we thank you for your thoughtful considerations, which strengthened the theoretical rigor and social relevance of the manuscript. Thank you.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

All previous concerns have been addressed. Please adjust the formatting of the footnotes for the tables. It seems like they are not appearing right below the table. 

Author Response

Dear reviewer,

Thank you for your feedback regarding the changes that were made. Furthermore, we would like to inform you about the adjustment to the formatting of the table footnotes, which appear below the table immediately after the source. All table footnotes have been reviewed and the formatting corrected to ensure they appear correctly positioned below their respective tables. We have also verified the consistency of the style applied to all tables to ensure uniformity throughout the manuscript. Thank you.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, 

thank you for making the necessary changes. Adding a few more recent references of syndemics to this study is necessary to strengthen your argument. Merrill Singer has published articles and books after 2020. Please build on it throughout your manuscript, e.g., line 551-560 or 664-700. Just mentioning the syndemic makes less justice with this approach. 

Author Response

Dear Reviewer,

Thank you for your observation and suggestion for improvement. Following your recommendation, we have included more recent references on syndemics in the manuscript, especially publications by Merrill Singer after 2020, which deepen and update the conceptual debate, broaden the theoretical context, and strengthen the study's argument. We hope these additions fully meet your request. Thank you.