Maternal Mortality Trends in the Context of the ReMaP Project and the Implementation of the Alyne Network: A Time-Series Analysis

Objective: Analyze maternal mortality trends in the state of São Paulo, comparing the periods before and after the emergence and implementation of the ReMaP Project (Restructuring and Redesign of the Maternal and Perinatal Care Network in the State of São Paulo) and the establishment of the Alyne Network (Rede Alyne), while stratifying the data according to the sociodemographic and clinical characteristics of pregnant and postpartum women of reproductive age (10–49 years). Methods: Retrospective epidemiological, ecological and longitudinal study with time series analysis of maternal deaths in women aged 10 to 49 years in São Paulo, from 2010 to 2025. Data were extracted from the Brazilian Obstetric Observatory panel and divided into two periods: pre-pandemic (2010–2019) and pandemic/post-pandemic (2020–2025). Descriptive and inferential analysis was carried out using Pearson's chi-square test (p< 0.05). Results: 2,795 deaths were analyzed in the first period and 1,499 in the second. There was a reduction in the proportion of deaths among white women (55.7% to 50.8%) and an increase among brown women (33.0% to 36.2%) and black women (8.6% to 11.3%). There was a drop in direct maternal deaths (60.0% to 50.0%) and an increase in indirect deaths (37.2% to 45.6%). The hospital environment concentrated more than 91% of cases. Although medical assistance before death increased (70.9% to 79.3%), the performance of autopsies fell from 36.7% to 18.3%, and investigation by committees decreased from 42.9% to 32.2%. Conclusions: The temporal transition highlighted the increase in indirect causes and the worsening of racial inequalities in maternal mortality in São Paulo. Despite the expansion of pre-death assistance registration, weaknesses were detected in post-pandemic epidemiological surveillance, indicating the need to strengthen investigation committees and improve care networks.