Short abstract
At the time of writing 124 pregnant or postpartum women in Brazil have died due to COVID‐19 (representing a mortality rate of 12.7%), a figure that currently surpasses the total number of COVID‐19‐related maternal deaths reported throughout the rest of the world.
Keywords: COVID‐19, Health services accessibility, Health status indicators, Maternal death, Maternal mortality, SARS‐CoV‐2
1. INTRODUCTION
Initial reports at the onset of the COVID‐19 pandemic indicated that the obstetric population did not appear to be at higher risk of developing severe symptoms of COVID‐19 than the general population. 1 However, following recent publications showing that pregnancy and the postpartum period might indeed pose additional risks for both women and babies, these preliminary observations urgently require review. 2 Explanations for heightened risk may include relative immunodeficiency associated with maternal physiological adaptations, as well as organic response to virus infections.
The present study aims to describe outcomes for pregnant and postpartum women with COVID‐19 disease from the first documented case in Brazil on February 26, 2020 until June 18, 2020 using the Brazilian Ministry of Health’s Acute Respiratory Distress Syndrome (ARDS) Surveillance System. According to Brazilian ethics regulatory requirements, literature search and secondary analysis of publicly available anonymized data do not require ethical approval by an Institutional Review Board.
ARDS caused by COVID‐19 was diagnosed in 978 pregnant and postpartum women in Brazil during the study period. Brazil currently has no universal testing policy for the obstetric population. Since only women presenting with severe symptoms are tested, it is certain that the number of COVID‐19 infections in this population is underreported. The present study found 124 deaths of pregnant or postpartum women (Table 1), a figure which is 3.4 times higher than the total number of COVID‐19‐related maternal deaths reported throughout the rest of the world at the time of writing. 3 , 4 , 5 , 6 , 7 The current mortality rate is 12.7% in the Brazilian obstetric population, which is also higher than rates reported so far in the literature. 3 , 4 , 7 Notably, the mortality rate was higher for cases identified in the postpartum period than during pregnancy, likely reflecting the onset timing of COVID‐19 symptoms.
Table 1.
Characteristics of Brazilian COVID‐19 obstetric cases according to the outcome (recovery or death) (n = 978).
| Recovery | Death | p‐value b | |||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Total | 854 | 87.3 | 124 | 12.7 | — |
| Age—mean (SD) | 29.5 (6.9) | 31.5 (7.5) | — | ||
| Timing in relation to birth (at notification date) | |||||
| Pregnancy | 680 | 90.2 | 74 | 9.8 | <0.001 |
| Postpartum | 174 | 77.7 | 50 | 22.3 | |
| Race | |||||
| White | 212 | 90.2 | 23 | 9.8 | 0.116 |
| Non‐white | 440 | 86.1 | 71 | 13.9 | |
| Missing/Unknown | 202 | 87.1 | 30 | 12.9 | |
| Region | |||||
| North | 116 | 84.7 | 21 | 15.3 | 0.032 |
| Northeast | 245 | 83.9 | 47 | 16.1 | |
| Midwest | 32 | 97.0 | 1 | 3.0 | |
| Southeast | 426 | 88.6 | 55 | 11.4 | |
| South | 35 | 100.0 | 0 | 0.0 | |
| Prevalence of selected comorbidities | |||||
| Cardiovascular disease | |||||
| Yes | 41 | 6.7 | 13 | 16.3 | 0.002 |
| No | 573 | 93.3 | 67 | 83.7 | |
| Missing/Unknown (%) a | 28.1 | 35.5 | |||
| Diabetes (gestational or previous) | |||||
| Yes | 67 | 20.8 | 22 | 33.8 | 0.023 |
| No | 255 | 79.2 | 43 | 66.2 | |
| Missing/Unknown (%) a | 62.3 | 47.6 | |||
| Obesity | |||||
| Yes | 31 | 10.3 | 13 | 21.3 | 0.016 |
| No | 270 | 89.7 | 48 | 78.7 | |
| Missing/Unknown (%) a | 64.8 | 50.8 | |||
| Asthma | |||||
| Yes | 18 | 5.9 | 5 | 9.3 | 0.360 |
| No | 285 | 94.1 | 49 | 90.7 | |
| Missing/Unknown (%) a | 64.5 | 56.5 | |||
| Frequency of supportive care | |||||
| ICU admission | |||||
| Yes | 134 | 17.5 | 73 | 72.3 | <0.001 |
| No | 630 | 82.5 | 28 | 27.7 | |
| Missing/Unknown (%) a | 10.5 | 18.5 | |||
| Respiratory support | |||||
| Invasive | 32 | 4.4 | 66 | 64.0 | <0.001 |
| Non‐invasive | 197 | 27.1 | 22 | 21.4 | |
| None | 497 | 68.5 | 15 | 14.6 | |
| Missing/Unknown a | 15.0 | 16.9 | |||
Missing/unknown percentages refers to the number of cases with missing values or coded as unknown among the total number of cases in each row (854 cure and 124 death cases).
Chi‐square test.
Brazil’s elevated COVID‐19 mortality rate in pregnant women and women in the postpartum period might have several explanations. In Brazil, obstetric care is beset by chronic problems that can affect maternal and perinatal outcomes, such as poor quality antenatal care, insufficient resources to manage emergency and critical care, racial disparities in access maternity services, obstetric violence, and the pandemic poses additional barriers for access to health care. Additionally, the rate of cesarean sections is among the highest in the world and questions remain regarding the increased risk of postoperative morbidity and mortality for patients with COVID‐19 undergoing surgery. 8
Our findings identified diabetes, cardiovascular disease, and obesity as significant conditions associated with mortality in the obstetric population, similar to the general population (Table 1). Of the 978 positive cases, 207 (21.2%) were admitted to ICU (134 recovered cases and 73 fatal cases) It is noteworthy that 22.6% of the women who died were not admitted to the ICU, and only 64.0% had invasive ventilation. No ventilatory support was offered to 14.6% of all fatal cases, while the remaining 21,4% received non‐invasive ventilation only. Failure to adequately report these variables in the surveillance system cannot be ruled out due to its retrospective nature. The data seem to reflect that obstetric patients may face barriers to access ventilators and intensive care. This is not a novel issue within the Brazilian healthcare system and it is aggravated by the COVID‐19 pandemic; shortage of healthcare providers and lack of intensive care resources are well‐described chronic challenges in Brazilian maternity services. 9 A similar observation was described in Mexico: of seven reported maternal deaths, only two were admitted to an ICU and one received mechanical ventilation. 5 So far, the number of maternal deaths due to COVID‐19 represents almost 10% of overall annual maternal deaths in Brazil. Contingency actions focused on maternal health are urgently needed to improve both antenatal care and access to intensive care for pregnant and postpartum women.
AUTHOR CONTRIBUTIONS
MLST, MOM, CBA, MNP, MMRA, LK, and RK equally contributed to study conception and design, data collection, analysis, and interpretation. MLST, MOM, RK, and CBA wrote the first draft of the paper. All authors reviewed and approved the final manuscript.
CONFLICTS OF INTEREST
The authors have no conflicts of interest.
Acknowledgments
The authors would like to thank all members of the Brazilian Group for Studies of COVID‐19 and Pregnancy for their efforts in supporting this work.
REFERENCES
- 1. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Westgren M, Pettersson K, Hagberg H, Acharya G. Severe maternal morbidity and mortality associated with COVID‐19: The risk should not be downplayed. Acta Obstet Gynecol Scand. 2020;99:815–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women hospitalised with confirmed SARS‐CoV‐2 infection in the UK a national cohort study using the UK Obstetric Surveillance System (UKOSS). BMJ. 2020;369:m2107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Kayem G, Alessandrini V, Azria E, et al. A snapshot of the Covid‐19 pandemic among pregnant women in, France. J Gynecol Obstet Hum Reprod. 2020:1–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Lumbreras‐Marquez MI, Campos‐Zamora M, Lizaola‐Diaz de Leon H, Farber MK. Maternal mortality from COVID‐19 in Mexico. Int J Gynecol Obstet. 2020;150:266–267. [DOI] [PubMed] [Google Scholar]
- 6. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, et al. maternal death due to COVID‐19 disease. Am J Obstet Gynecol. 2020;223:109.e1–109.e16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Ellington S, Strid P, Tong VT, et al. Characteristics of women of reproductive age with laboratory‐confirmed SARS‐CoV‐2 infection by Pregnancy Status — United States, January 22–June 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:769–775. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Nahshon C, Bitterman A, Haddad R, Hazzan D, Lavie O. Hazardous postoperative outcomes of unexpected COVID‐19 infected patients: A call for global consideration of sampling all asymptomatic patients before surgical treatment. World J Surg. 2020;44:2477–2481. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. De Azevedo Bittencourt SD, Domingues RMSM, Da Costa Reis LG, Ramos MM, Do Leal C. Adequacy of public maternal care services in Brazil. Reprod Health. 2016;13:120. [DOI] [PMC free article] [PubMed] [Google Scholar]