Increasing maternal mortality associated with COVID‐19 and shortage of intensive care is a serious concern in low‐resource settings

1.

Sir,

We read with interest the article by Collin et al that described an increased risk of requiring intensive care in pregnant or postpartum women with SARS‐CoV‐2 infection, even when considering only cases needing invasive mechanical ventilation (relative risk [RR] 3.49; 95% confidence interval [CI] 1.89‐6.52). ¹ The results of this study have implications for countries with limited resources, such as Brazil, the current epicenter of the COVID‐19 pandemic. Maternal deaths due to COVID‐19 were not reported in initial studies from China. ² However, it does seem to happen. A recent study reported a 3.4‐times higher mortality in pregnant and postpartum women with COVID‐19 in Brazil compared with the total number of COVID‐19‐related maternal deaths reported so far. ³ In the Brazilian series, 54.83% of deaths occurred in the north and northeast regions, ³ which have the highest maternal mortality ratio in Brazil: 80.8 and 67.1 per 100 000 live births, respectively. ⁴ Moreover, 27.7% of the patients who died were not admitted to the ICU and 14.6% of them did not receive any type of ventilatory support. ³ The limited resources available due to the collapse of the Brazilian health system was obvious from this case series. ⁵ Unfortunately, there is a substantial risk of this happening in many other low‐ and middle‐income countries around the world, unless their governments allocate resources and prioritize saving mothers´ lives. Although the fertility rate and maternal mortality ratio in Brazil and Sweden are not comparable, we believe that the Brazilian report ³ supports the findings of the study by Collin et al, ¹ as far as we know, the first study to show an increase in serious morbidity among pregnant and puerperal women with COVID‐19. In light of this and other more recent studies, universal testing of pregnant women for COVID‐19 and a low threshold for admitting pregnant women to hospital and intensive care unit a would be justified.