Persistent subnational disparities in the recovery of maternal mortality magnitude in Brazil after the COVID-19 pandemic

BACKGROUND: Maternal mortality reflects the quality of obstetric care and the efficiency of health systems. Brazil faced structural challenges even before the pandemic, with marked regional disparities. COVID-19 worsened the scenario, increasing maternal mortality due to direct complications of the virus and the overload of health services, which hindered access to prenatal care, safe delivery, and emergency obstetric services. This study aimed to assess state-level temporal trajectories of maternal mortality in Brazil, with emphasis on the pandemic shock, post-pandemic recovery, and the persistence of interstate inequalities. METHODS: We analyzed annual maternal mortality ratios (MMR) for Brazil, the 26 states, and the Federal District from 2000 to 2023 using interrupted time-series segmented regression. Segmented models estimated the pre-pandemic trend, the immediate level change in 2020, the slope change during 2020-2022, and the early recovery phase from 2022 onward, with Newey-West robust standard errors. To assess changes in territorial inequality over time, we calculated the median absolute deviation (MAD), coefficient of variation (CV), and p90/p10 ratio across federative units. RESULTS: Before 2020, maternal mortality in Brazil showed stagnation, with persistent interstate disparities already evident. Segmented regression identified a modest but significant pre-pandemic upward trend, a marked worsening during the COVID-19 period, and an early post-pandemic decline. However, inequality widened substantially during the pandemic, and the subsequent decline did not fully restore the previous territorial pattern. State-level analyses confirmed marked heterogeneity in baseline levels. CONCLUSION: The recovery observed in the post-pandemic period suggests health system resilience, but regional disparities remain stark and still threaten progress toward SDG 3.1. Meeting SDG 3.1 will require targeted action in historically vulnerable states, stronger prenatal and obstetric care networks, and improved surveillance of maternal deaths.