Worldwide maternal deaths due to COVID‐19: A brief review

Trends in Maternal, Fetal, and Infant Mortality in the US, 2000-2023

Importance

Accurately measuring maternal mortality trends has been challenging due to changes in data collection. This work disambiguates trends from the effects of introducing the pregnancy checkbox on death certificates and also analyzes closely related fetal and infant mortality.

Objective

To describe trends in maternal, fetal, and infant deaths since 2000, including the impact of the COVID-19 pandemic.

Design, Setting, and Participants

A national, population-level, epidemiological, cross-sectional analysis during 2000 to 2023 was conducted as well as a staggered difference-in-differences analysis on the pregnancy checkbox, using the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database on underlying causes of death in the US to identify maternal, infant, and fetal deaths. Study population was restricted to mothers aged 15 to 44 years for all definitions of maternal mortality.

Exposures

Staggered introduction of the pregnancy checkbox on death certificates across different states.

Main Outcomes and Measures

Longitudinal study (2000-2023) reporting crude rates per 100 000 population for adjusted maternal mortality and per 1000 population for fetal and infant mortality at the national level and by US Census Bureau-designated main census regions, age groups, and race and ethnicity. Staggered difference-in-differences counterfactuals (1999-2023) on impact of pregnancy checkbox.

Results

The introduction of the pregnancy checkbox was associated with 6.78 (95% CI, 1.47-12.09) deaths per 100 000 live births increase in reported maternal mortality, 66% (95% CI, 14%-117%) of the total increase from 2000 to 2019, with a smaller impact on maternal mortality excluding cause unspecified (adjusted maternal death rates). Adjusted maternal death rates remained consistently between 6.75 (95% CI, 5.97-7.61) to 10.24 (95% CI, 9.22-11.34) per 100 000 live births from 2000 until 2021, when it peaked at 18.86 (95% CI, 17.48-20.32); the rate dropped to 10.23 (95% CI, 9.22-11.32) in 2022. The death rates of Native American or Alaska Native women increased the most during the COVID-19 period, almost tripling from 2011 to 2019 (10.70 per 100 000 live births; 95% CI, 7.64-14.57) to the 2020 to 2022 period (27.47 per 100 000 live births; 95% CI, 18.39-39.45). The death rates of non-Hispanic Black women were highest across time-approximately triple the rate of non-Hispanic White women in each time period. Infant death rates per 1000 live births dropped from 6.93 (95% CI, 6.85-7.01) in 2000 to 5.44 (95% CI, 5.36-5.51) in 2020, increasing slightly to 2018 levels in 2021 to 2023. Fetal death rates per 1000 live births decreased from 6.28 (95% CI, 6.16-6.31) in 2005 to 5.53 (95% CI, 5.45-5.60) in 2022.

Conclusion and Relevance

Using difference-in-differences analyses, results of this study reveal that the pregnancy checkbox explained much of the observed increase in maternal mortality before the COVID-19 pandemic. Nevertheless, results of this cross-sectional study suggest that, even adjusting for pregnancy checkbox effects, most groups saw increases from 2011 to 2019 to the 2020 to 2022 period, indicating that the COVID-19 pandemic led to worse outcomes. The findings demonstrate the relevance of public health emergencies to maternal health outcomes.

COVID-19 and pregnancy: a comprehensive study of comorbidities and outcomes

OBJECTIVES

This study aimed to investigate the impact of pregnancy and pre-existing comorbidities on COVID-19 infections and associated complications of hospitalisation and mortality in women of reproductive age (WRA). The study also compared the risk of severe COVID-19 complications between pregnant women (PW) and non-pregnant women (NPW) with and without pre-existing comorbidities. Special focus was placed on some understudied comorbidities of immunosuppression, chronic renal disease and chronic obstructive pulmonary disease (COPD).

METHODS

The study utilized anonymized patient-related information for a population of 7,342,869 WRA from the Mexican Ministry of Health data repository on COVID-19. Descriptive variables were characterized using frequencies, percentages, means, and standard deviations. Adjusted odds ratios (aORs) were used to assess the associations between risk factors and outcomes of hospitalisation and mortality. The study covered the entire COVID-19 pandemic period from January 30, 2020, to May 5, 2023.

RESULTS

The findings revealed that PW were not more likely to get COVID-19 infections than NPW. PW with COVID-19 infections were more likely to require hospital admission, intubation treatments, and ICU admission compared to NPW with COVID-19. PW with immunosuppression had an increased odds ratio (aOR) of getting COVID-19 infections compared to NPW (PW: aOR = 1.0396; NPW: aOR = 0.8373). NPW with immunosuppression had higher risk of mortality (all-cause death: aOR = 1.7084; COVID-19-associated death: aOR = 1.4079) and hospitalisation (all-cause hospitalisation: aOR = 4.1328; COVID-19-associated hospitalisation: aOR = 3.0451) than NPW without immunosuppression. Renal disease was identified as a concerning pre-existing condition that increased the risks of COVID-19 associated mortality/hospitalizations and all-cause mortality/hospitalizations for both PW and NPW. NPW with renal disease had much higher odds ratio (aOR) of either COVID-19-associated-hospitalisations (NPW: aOR = 8.639; PW: aOR = 1.7603) or all-cause hospitalisations (NPW: aOR = 8.8594; PW: aOR = 1.786) than PW with renal disease.

CONCLUSIONS

This study provides valuable insights into the impact of pregnancy and pre-existing comorbidities on COVID-19 outcomes in WRA. The findings underscore the importance of considering demographic factors and pre-existing comorbidities in the management of PW with COVID-19. The study also highlights the need for further research to understand the unique impacts of different comorbidities, particularly immunosuppression and renal disease, on COVID-19 outcomes in WRA.

Evaluation of the Relationship between Early Clinical Manifestations and Changes in Biochemical, Inflammatory, and Coagulation Parameters and the Prognosis of Pregnant Women with COVID-19 Admitted to the ICU

Background

In the SARSCov2 virus epidemic, pregnant women are more susceptible to infectious diseases due to changes in biochemical parameters and are at higher risk of severe respiratory disease and pneumonia. This study aimed to evaluate the biochemical, inflammatory and coagulation parameters in pregnant women with severe disease conditions (as one of the high-risk groups) as well as prognosis and outcome.

Materials and Methods

This cross-sectional study was performed on 135 pregnant women with COVID-19 admitted to ICU. Demographic and clinical information and laboratory parameters of the patients were evaluated and recorded at the time of admission and in the next follow-up until discharge or death in addition to the outcome and also the pregnancy outcome.

Results

The mortality rate of pregnant women with COVID-19 was 9.6%. The mortality rate decreases with increasing Hb (OR (95% CI): 0.68 (0.47-0.99); P value = 0.043) and lymphocytes (OR (95% CI): 0.92 (0.85-0.96); P value = 0.028) and will increase significantly with increasing PT (OR (95% CI): 1.24 (1.01-1.51); P value = 0.037), INR (OR (95% CI): 1.89 (1.26-2.25); P value = 0.004), D-dimer (OR (95% CI): 1.68 (1.10-2.08); P value = 0.027), and LDH (OR (95% CI): 1.20 (1.01-1.61); P value = 0.010).

Conclusion

According to the results of the present study, inflammatory factors such as leukocytes, neutrophils, NLR, CRP have an increasing and lymphocytes have a decreasing trend, so that lymphocytopenia is more common in non-survivors. In addition, increase of PT, INR, D-dimer and LDH and decrease of Hb were significantly associated with increased chance of mortality. But fibrinogen, ferritin, ALT and AST were not significantly associated with mortality in these women.

Maternal mortality: protocol of a study integrated to the Birth in Brazil II survey

The Maternal Mortality Study conducts a hospital investigation of maternal deaths that occurred in 2020/2021 in the maternity hospitals sampled by the Birth in Brazil II survey, with the following objectives: estimate the maternal mortality underreporting; calculate a correction factor and the corrected (MMR); validate the causes of maternal mortality reported in the death certificate (DC); and analyze the factors associated with maternal mortality. The Birth in Brazil II includes approximately 24,250 puerperal women distributed in 465 public, private, and mixed hospitals with ≥ 100 live births/year in the five macroregions of Brazil. The Maternal Mortality Study data will be completed using the same Birth in Brazil II questionnaire, from the consultation of hospital records. Trained obstetricians will fill out a new DC (redone DC) from independent analysis of this questionnaire, comparing it to official data. The database of the investigated deaths will be related to the deaths listed in the Mortality Information System of the Brazilian Ministry of Health, allowing the estimation of underreporting and calculation of the corrected MMR. To calculate the reliability of the causes of death, the kappa test and prevalence-adjusted kappa with 95% confidence interval will be used. A case-control study to estimate the risk factors for maternal mortality will be developed with the investigated deaths (cases) and the controls obtained in the Birth in Brazil II survey, using conditional multiple logistic regression models. We expect this research to contribute to the correction of the underreporting of maternal mortality and to a better understanding of the determinants of the persistence of a high MMR in Brazil.

Outcome of pregnancy in sickle cell anemia patients with COVID-19 infection

Sickle cell anemia (SCA) is a multisystem disease, associated with increased risk for infection and thromboembolic disease, and pregnancy is a stressor for patients with SCA. In general, coronavirus disease 2019 (COVID-19) infection in SCA is associated with a favorable outcome. Literature of pregnancy in SCA with COVID is scarce. We report a case series study of pregnant women with SCA, who are confirmed positive for COVID-19 from May 2020 to March 2021. These patients showed generally mild-to-moderate disease and presented predominantly with fever and painful crisis. They showed a significant drop in Hb from baseline, and they received low-molecular-weight heparin prophylaxis (LMWH) and blood transfusion. The outcome of pregnancy is satisfactory, although the mean birth weight was significantly lower than that reported from the same SCA population.

Severe Covid-19 in pregnant and postpartum women admitted to an intensive care unit: A retrospective cohort study

BACKGROUND

SARS-CoV-2 infection is associated with worse maternal and fetal outcomes. This study aims to describe the characteristics of pregnant and postpartum women with severe Covid-19 admitted to ICU.

METHODS AND FINDINGS

It's a retrospective cohort study evaluating pregnant and postpartum women referenced to a specialized ICU between May 2020 and June 2022. Covid-19 was confirmed with RT-PCR or rapid antigen test on a nasopharyngeal swab. Variables were described by median and IQR when numerical, and by frequency and percentage when categorical. OR with 95% CI were calculated for the evaluation of factors related to death. P-values were calculated using Pearson's ꭓ2-test, Fisher's exact test, Wilcoxon rank sum test, and Kruskall-Wallis test, and statistical significance was established as < 0·05. Missing data were excluded. All statistical analysis were performed using R software version 4.2.2. Of the 101 admissions, 85 (84·2%) were of pregnant women. Obesity (23·0%) and systemic arterial hypertension (13·0%) were the most prevalent medical conditions. Sixty-six (65·3%) were admitted using some type of oxygen support. Forty-seven (46·5%) evolved to mechanical ventilation. There were 61 events considered obstetric complications, with 8 stillbirths/fetal losses. The overall lethality was 15·8%. Pregnancy interruption, need for non-invasive mechanical ventilation, level of oxygen support at admission, prone maneuver, hemodialysis, and healthcare-related infections were factors associated with death. Evaluating the WHO 7-category ordinary scale, there was a trend of increase in the risk of death with higher punctuation, with a statistically significant difference of women with 5 (OR = 7·27; 95% IC = 1·17-194; p = 0·031) or 6 points (OR = 12·0; 95% IC = 1·15-391; p = 0·038) when compared to the ones with 3 points, i.e., of women admitted with a high-flow non-rebreathing mask or invasive mechanical ventilation, compared with the ones admitted at room air, respectively. The main limitations of this study are the relatively small number of participants, and the use of data derived of medical records-which are susceptible to misclassification and variable amounts of missing data.

CONCLUSIONS

Pregnant and postpartum women with severe Covid-19 have high lethality and a high incidence of clinical and obstetric complications. These findings support that this population should be prioritized in public health strategies that address Covid-19.

Clinical, epidemiological and laboratory characteristics of cases of Covid-19-related maternal near miss and death at referral units in northeastern Brazil: a cohort study

Objective: Covid-19 poses a major risk during pregnancy and postpartum, resulting in an increase in maternal mortality worldwide, including in Brazil; however, little research has been conducted into cases of a near miss. This study aimed to describe the frequency of COVID-19-related near miss and deaths during pregnancy or in the postpartum in referral centers in northeastern Brazil, as well as the clinical, epidemiological, and laboratory characteristics of the women who experienced a severe maternal outcome.Methods: A retrospective and prospective cohort study was performed between April 2020 and June 2021 with hospitalized pregnant and postpartum women with a diagnosis of COVID-19 confirmed by real-time polymerase chain reaction (RT-PCR). Data from five tertiary hospitals in northeastern Brazil were evaluated. Descriptive statistical analysis was performed using Epi Info, version 7.2.5.0.Results: A total of 463 patients were included. Of these, 64 (14% of the sample) had a severe maternal outcome, with 42 cases of near miss (9%) and 22 maternal deaths (5%). Patients who had a severe maternal outcome were predominantly young (median age 30 years) and 65.6% were black or brown-skinned. The women had between 6 and 16 years of schooling; 45.3% had a stable partner; 81.3% were pregnant at the time of admission to the study; and 76.6% required a Cesarean section. The great majority (82.8%) had severe acute respiratory syndrome (SARS). Other complications included hypertensive syndromes (40.6%), pneumonia (37.5%), urinary tract infections (29.7%), acute renal failure (25.0%) and postpartum hemorrhage (21.9%). Sepsis developed in 18.8% of cases, neurological dysfunction in 15.6%, and hepatic dysfunction and septic shock in 14.1% of cases each. The relative frequency of admission to an intensive care unit was 87.5%, while 67.2% of the patients required assisted mechanical ventilation, and 54.7% required noninvasive ventilation. Antibiotics were prescribed in 93.8% of cases and corticosteroids in 71.9%, while blood transfusion was required in 25.0% of cases and renal replacement therapy in 15.6%. Therapeutic anticoagulants were administered to 12.5% of the patients. Of the patients who had a severe maternal outcome, the frequency of respiratory dysfunction was 93.8%, with 50.0% developing neurological dysfunction and 37.5% cardiovascular dysfunction. Hematological dysfunction was found in 29.7%, renal dysfunction in 18.8%, and uterine dysfunction in 14.1%. Hepatic dysfunction occurred in 7.8% of the sample. The near-miss ratio for Covid-19 was 1.6/1000 live births and the maternal mortality ratio for Covid-19 was 84.8/100,000 live births, with a mortality index of 34.4% in the sample.Conclusion: This study revealed a low Covid-19-related maternal near miss (MNM) ratio of 1.6/1000 live births and a high Covid-19-related maternal mortality ratio (MMR) of 84.81/100,000 live births. The mortality index was also high. Most of the patients were admitted while pregnant, were young, married and black or brown-skinned, and none had completed university education. The majority had SARS and required admission to an intensive care unit and mechanical ventilation. Most were submitted to a Cesarean section.

Devastating pregnancy outcomes in the second wave of the COVID-19 pandemic

BACKGROUND

This study analyzed pregnancy outcomes in postpartum women who were infected with COVID-19 during their pregnancy in resource-limited settings during the second wave of the COVID-19 pandemic.

MATERIALS AND METHODS

This cross-sectional study included all pregnant women with COVID-19 at a tertiary referral hospital in Surabaya, Indonesia, from June to August 2021. Patients were classified according to clinical presentation into asymptomatic-mild, moderate, and severe-critical. Data regarding their basic maternal characteristics, clinical symptoms, delivery, and neonatal outcomes were collected and analyzed across these severity levels through ANOVA, Kruskal-Wallis, or Mann-Whitney U test by incorporating SPSS Statistics software version 29.0.

RESULTS

During the second wave of COVID-19 in Indonesia, a total of 184 COVID-19 cases were reported, with high mortality rate (22%). Only 26.6% of these cases were asymptomatic-mild, and the remaining 73.4% had more severe conditions. The severe-critical group had significantly lower gestational age, slower onset of diseases/symptoms, and higher maternal death proportions than the other two groups (P < 0.001). Clinical symptoms, vital signs, and inflammatory markers (NLR, CRP, and procalcitonin) were also significantly worse in the severe-critical group than in the other groups (P < 0.05). Consequently, severe cases showed a higher cesarean section rate (P = 0.034), lower birth weight, lower Apgar score, higher incidence of perinatal deaths (P < 0.001), and higher incidence of neonatal support (P = 0.003).

CONCLUSIONS

The study's findings specified the devastating consequences of second wave of COVID-19 in a resource-limited setting. Focus on improving the health system and health facilities' capacity is warranted to anticipate all possibilities of other pandemics in the future.

Morphological placental findings in women infected with SARS-CoV-2 according to trimester of pregnancy and severity of disease

INTRODUCTION

Placental morphology findings in SARS-CoV-2 infection are considered nonspecific, although the role of trimester and severity of infection are underreported. Therefore, we aimed to investigate abnormal placental morphology, according to these two criteria.

METHODS

This is an ancillary analysis of a prospective cohort study of pregnant women with suspected SARS-CoV-2 infection, managed in one maternity, from March 2020 to October 2021. Charting of clinical/obstetric history, trimester and severity of COVID-19 infection, and maternal/perinatal outcomes were done. Placental morphological findings were classified into maternal and fetal circulatory injury and acute/chronic inflammation. We further compared findings with women with suspected disease which tested negative for COVID-19. Diseases' trimester of infection and clinical severity guided the analysis of confirmed COVID-19 cases.

RESULTS

Ninety-one placental discs from 85 women were eligible as a COVID-19 group, and 42 discs from 41 women in negative COVID-19 group. SARS-CoV-2 infection occurred in 68.2% during third trimester, and 6.6% during first; 16.5% were asymptomatic, 61.5% non-severe and 22.0% severe symptomatic (two maternal deaths). Preterm birth occurred in 33.0% (one fetal death). Global maternal vascular malperfusion (MVM) were significant in COVID-19 group whether compared with negative COVID-19 tests group; however, fetal vascular malperfusion lesions and low-grade chronic villitis were not. Three placentas had COVID-19 placentitis. Decidual arteriopathy was associated with infection in first/mid trimester, and chorangiosis in asymptomatic infections.

DISCUSSION

Placental abnormalities after an infection by COVID-19 were more frequent after first/mid-trimester infections. Extensive placental lesions are rare, although they may be more common upon underlying medical conditions.

Evaluation of Maternal and Fetal Outcomes in Pregnant Women with COVID-19 based on Different Trimesters

Background

COVID-19 is the leading cause of the recent pandemic in the globe. This disease might have different effects on the maternal and fetal outcomes in pregnancy. The aim of this study was to assess these outcomes in pregnant women with COVID-19 infections in different trimesters.

Materials and Methods

This is a prospective cohort study that was performed in February 2020 to August 2021 in Isfahan on 430 pregnant women with definite diagnosis of COVID-19 infection admitted to our medical centers. The included cases were followed based on the gestational age in which they were diagnosed with COVID-19 infection. Patients were divided into three groups (first, second, and third trimesters) based on COVID-19 infection.

Results

The frequency of requiring mechanical ventilation was higher in mothers with COVID-19 in the second trimester (P = 0.049) and the frequency of PIH was significantly higher in mothers with COVID-19 in the third trimester compared to other women (P = 0.009). Fetal growth restriction (FGR) was also observed in 22 patients (5.3%) that was mostly observed with COVID-19 in the third trimester (P = 0.012). Oligohydramnios and fetal distress leading to C/S were observed in 19 patients (4.6%) and 12 patients (2.9%), respectively. The majority of maternal mortality was among cases with COVID-19 infection in the third trimester (44.4%).

Conclusion

We observed higher maternal and fetal complications in women especially those in the third trimester. Our results were in line with the findings of previous studies. Women with COVID-19 infection in the third trimester had highest frequencies of preterm labor and FGR.

Mental health penalties of having a child: findings from the China family panel studies

In recent years, the birth rate in China has rapidly declined. While much research has been done on the penalties in earnings that women incur when they fall behind men in the labor market due to childbirth, there has been little to no research on the mental health effects. This study addresses the gap in current literature by examining the mental health penalties that women experience after having a child in comparison to men. We applied econometric modeling to data collected from China Family Panel Studies (CFPS) and found that women experienced a significant, immediate, and long-run decline (4.3%) in life satisfaction after their first child, while men were unaffected. We also found that women experienced a significant increase in depression after their first child. This suggests mental health penalties since the mental health risk proxied by these two measurements is only significant for women. This is likely related to child penalties in labor market performance and childbirth-related physical health issues. When countries adopt multiple tools to stimulate the birth rate for economic growth, they must consider the implicit burden on women-especially the long-term negative effects on mental health.

Barriers and facilitators of vaccine hesitancy for COVID-19, influenza, and pertussis during pregnancy and in mothers of infants under two years: An umbrella review

BACKGROUND

Vaccination during pregnancy has been repeatedly demonstrated to be safe and effective in protecting against infection and associated harms for the mother, developing baby, and subsequent infant. However, maternal vaccination uptake remains low compared to the general population.

OBJECTIVES

An umbrella review to explore the barriers and facilitators to Influenza, Pertussis and COVID-19 vaccination during pregnancy and within 2 years after childbirth, and to inform interventions to encourage uptake (PROSPERO registration number: CRD42022327624).

METHODS

Ten databases were searched for systematic reviews published between 2009 and April 2022 exploring the predictors of vaccination or effectiveness of interventions to improve vaccination for Pertussis, Influenza, or COVD-19. Both pregnant women and mothers of infants under two years were included. Barriers and facilitators were organised using the WHO model of determinants of vaccine hesitancy through narrative synthesis, the Joanna Briggs Institute checklist assessed review quality, and the degree of overlap of primary studies was calculated.

RESULTS

19 reviews were included. Considerable overlap was found especially for intervention reviews, and the quality of the included reviews and their primary studies varied. Sociodemographic factors were specifically researched in the context of COVID-19, exerting a small but consistent effect on vaccination. Concerns around the safety of vaccination particularly for the developing baby were a main barrier. While key facilitators included recommendation from a healthcare professional, previous vaccination, knowledge around vaccination, and communication with and support from social groups. Intervention reviews indicated multi-component interventions involving human interaction to be most effective.

CONCLUSION

The main barriers and facilitators for Influenza, Pertussis and COVID-19 vaccination have been identified and constitute the foundation for policy development at the international level. Ethnicity, socioeconomic status, concerns about vaccine safety and side effects, and lack of healthcare professionals' recommendations, are the most relevant factors of vaccine hesitancy. Adapting educational interventions to specific populations, person-to-person interaction, healthcare professionals' involvement, and interpersonal support are important strategies to improve uptake.

Maternal and Neonatal Outcomes of COVID-19 Infection in Pregnancy

BACKGROUND

Limited data is available on the full spectrum of maternal COVID-19 infection in terms of pregnancy outcomes. The present study aimed to compare the maternal and neonatal outcomes of COVID-19 in infected and non-infected pregnant women.

METHODS

A dual-site retrospective cohort study was conducted in two tertiary hospitals in Isfahan, Iran. The sample included 104 infected and 210 non-infected hospitalized pregnant women. Odds ratios (OR) were estimated using multivariate logistic regression.

RESULTS

There were significant differences between COVID-19-infected and non-infected pregnant women regarding preterm labor (PTL) (odds ratio [OR]: 11.34, 95% confidence interval [CI]: 1.19-48.54, P=0.035); hospitalization days (OR: 7.21, 95% CI: 4.05-12.85, P≤0.001); cesarean section (CS) (OR: 4.76, 95% CI: 1.78-12.45, P=0.002); neonatal admission to neonatal intensive care unit (NICU) (OR: 1.28, 95% CI: 1.12-1.67, P=0.004); and neonatal respiratory distress (OR: 2.37, 95% CI: 1.02- 5.47, P=0.044). No significant association was found between COVID-19 infection and abortion (OR: 0.06, 95% CI: 0.01-1.45, P=0.084); stillbirth (OR: 1.84, 95% CI: 0.05-39.68, P=0.743); Apgar score (1 minute) (OR: 0.91, 95% CI: 0.74-1.13, P=0.382); Apgar score (5 minutes) (OR: 0.97, 95% CI: 0.81-1.18, P=0.765); and low birth weight (LBW) (OR: 4.76, 95% CI: 1.78-12.45, P=0.002).

CONCLUSION

PTL, CS, neonatal admission in NICU, neonatal respiratory distress, and hospitalization days were significantly higher in pregnant women with COVID-19 compared to those without infection.

Rates of depressive and anxiety symptoms in the perinatal period during the COVID-19 pandemic: Comparisons between countries and with pre-pandemic data

BACKGROUND

The COVID-19 pandemic was a significant threat to perinatal mental health. This study examined differences in clinically significant depression, anxiety, and co-morbid symptoms among pregnant and postpartum women across several countries and compared prevalence of perinatal depression and anxiety before and during the pandemic in each participating country.

METHODS

Participants were 3326 pregnant and 3939 postpartum women (up to six months postpartum) living in Brazil, Chile, Cyprus, Greece, Israel, Portugal, Spain, Turkey, and the United Kingdom. An online survey was completed between June 7th and October 31st 2020, and included the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder Screener (GAD-7). The pre-pandemic studies were identified through literature review.

RESULTS

Prevalence of clinically significant depression (EPDS≥13), anxiety (GAD-7 ≥ 10), and co-morbid (EPDS≥13 and GAD-7 ≥ 10) symptoms was 26.7 %, 20 % and 15.2 %, in pregnant women, and 32.7 %, 26.6 % and 20.3 %, in postpartum women, respectively. Significant between-country differences were found in all mental health indicators in both perinatal periods. Higher levels of symptoms were observed during (versus before) the pandemic, especially among postpartum women.

LIMITATIONS

Participants were mostly highly educated and cohabiting with a partner. The online nature of the survey may have limited the participation of women from vulnerable socio-economically backgrounds.

CONCLUSIONS

Our findings expand previous literature on the negative impact of the COVID-19 pandemic on perinatal mental health, by highlighting that this may be influenced by country of residence. Mental health care policies and interventions should consider the unique needs of perinatal women in different parts of the world.

Coagulation conundrum in obstetric anesthesia with COVID-19

Coronavirus disease (COVID-19) pandemic is an unprecedented public health calamity that has caused an immense setback to maternal health services in developing countries. In addition to morbidity and mortality caused by COVID-19 disease in parturient directly, the indirect adverse impact of lockdown imposed during pandemic causing loss of follow-up of patients with coexisting illness is significant. There are no standard protocols to manage COVID-19 patients with comorbid medical illness, who are not optimized during antenatal visits. We report an interesting case of an antenatal patient with COVID-19, with prosthetic aortic valve on warfarin with elevated International Normalized Ratio (INR) and severe pre-eclampsia, posted for emergency cesarean section.

COVID-19 related maternal mortality cases in associated with Delta and Omicron waves and the role of lung ultrasound

Objective

To present coronavirus disease-2019 (COVID-19) related maternal mortality in relation to Delta and Omicron waves and to investigate the role of lung ultrasound (LUS) in estimating mortality.

Materials and Methods

This retrospective cohort study was conducted in the obstetrics and gynecology clinic of a tertiary pandemic hospital between March 2020 and January 2022. The hospitalized pregnant women with COVID-19 diagnosis and maternal deaths were studied in relation with Delta and Omicron waves. The relationship between LUS scores of hospitalized patients and maternal mortality was explored.

Results

Thousand and sixty-five pregnant women were hospitalized because of COVID-19 infection. Fifty-one (4.79%) of these patients had critical sickness, 96 (9.01%) of them had severe illness, 62 (5.82%) of them were admitted to the intensive care unit and 28 (2.63%) of all hospitalized pregnant women had died. Of the 1.065 patients, 783 (73.5%) were hospitalized before the Delta wave and the maternal mortality rate was 1.28% (10/783), 243 (22.8%) were hospitalized during the Delta wave and the maternal mortality rate was 7% (17/243) [relative risk (RR)=5.478, 95% confidence interval (CI) (2.54-11.8), z=4.342, p<0.001]. During the Omicron wave 39 (3.66%) patients were hospitalized and the maternal mortality rate was 2.56% (1/39). Maternal mortality rates, according to LUS scores, were 0.37% (1/273) for LUS 0, 0.72% (2/277) for LUS 1, 2.58% (10/387) for LUS 2 and 11.72% (15/128) for LUS 3 respectively (LUS 3 vs. others; maternal mortality: RR=8.447, 95% CI (4.11-17.34), z=5.814, p<0.0001). There were no vaccinated patients in the study cohort.

Conclusion

The maternal mortality rate was relatively high, particularly during the Delta wave at our referral center. The Delta wave, delayed vaccination and vaccine hesitancy of pregnant women might have important roles in maternal mortality. Higher LUS scores should warn clinicians of an increased risk of maternal death.

Impact of the COVID-19 pandemic on the number of births in Pernambuco Brazil

This study aimed at analysing the potential effects of the COVID-19 pandemic on the time series and spatial patterns of live births in the state of Pernambuco, Brazil, from 2010 to 2021. This is an ecological study that applied intervention analysis in time series, with the goal to identify how projected data behaved in relation to observed data in the months December 2020 to November 2021, i.e. months representing conceptions from March2020 to April 2021. For the state of Pernambuco, a discrepancy up to +5.7% was found between the observed and projected data, while the respective difference for the São Francisco mesoregion showed the opposite trend with maximum discrepancy of -9%. The results did not indicate a clear change in the number of live births but supported the expected continuation of the downward trend of the previous years. Considering the importance of the number of live births in the context of demography, economy and public health, monitoring must be maintained to analyse the possible future impact of the COVID-19 pandemic on live birth projections.

Prevalence of Maternal Mortality and Clinical Course of Maternal Deaths in COVID-19 Pneumonia-A Cross-Sectional Study

Introduction

After initial studies suggested that pregnant women were not at a higher risk of complications due to COVID-19 infection. Recent investigations from Sweden and the US have indicated that pregnant and postpartum women are at increased risk of severe complications associated with COVID-19. This study aims to find out the prevalence of maternal mortality and the clinical course of maternal mortality cases due to COVID-19 pneumonia.

Methodology

A cross-sectional study was conducted from May 1st, 2020, to April 30th, 2021, at Postgraduate Institute and YCM Hospital Pimpri Pune (Maharashtra), a dedicated COVID hospital during COVID pandemic. During study period, all pregnant women who were diagnosed to have COVID-19 infection by RT PCR/Rapid Antigen Test were admitted and were enrolled for the study.

Aim

To audit the maternal mortality due to COVID-19 infection.

Primary

To estimate the prevalence of maternal mortality due to COVID-19 infection in obstetric patients.

Secondary

To systematically study and analyze the clinical course of infection in mothers who had mortality due to COVID-19 pneumonia. Data collected in standard format regarding Demography, clinical presentation, need for ICU/HDU, CXR findings, laboratory parameters and cases with maternal mortality were studied in detail to fulfill the study objectives.

Results

Among 871 COVID-19 cases diagnosed during pregnancy, nine patients had maternal mortality due to covid pneumonia. There was no obvious obstetric cause for mortality in these cases. The prevalence of maternal mortality was 0.01 (1.03%). Cases with maternal mortality were mostly in 3rd Trimester (5 of 9 cases) and presented with moderate to severe illness with breathlessness and myalgia in all 9 cases, cough and fever in 7 out of 9 cases, Tachypneoa was noted in all patients. Saturation below 90 in 6 cases and below 94 in 3 cases. Chest X-ray showed bilateral lung affection in all 9 cases. Leukocytosis with raised N:L ratio was predominantly seen, thrombocytopenia noted in 5 cases and elevated levels of acute phase reactants and inflammatory markers such as CRP, S. ferritin, ESR, LDH, D-dimer and S. fibrinogen was observed. None of the study participants received vaccine for COVID-19.

Conclusions

COVID-19 pneumonia is an additional toll for maternal mortality. Obstetric patients in 2nd and 3rd trimester having COVID-19 infection with late presentation to hospital, moderate to severe disease (RR > 30 min), with raised inflammatory markers (N:L ratio, CRP, Ferritin, d-Dimer, etc.) at presentation, having bilateral lung affection are at risk of poor maternal outcome.

"I Was Facilitating Everybody Else's Life. And Mine Had Just Ground to a Halt": The COVID-19 Pandemic and its Impact on Women in the United Kingdom

A growing body of research has highlighted the disproportionately negative impact of the COVID-19 pandemic on women globally. This article contributes to this work by interrogating the lived realities of sixty-four women in the United Kingdom through semi-structured in-depth interviews, undertaken during the first and second periods of lockdown associated with COVID-19 in 2020. Categorizing the data by subgroup of women and then by theme, this article explores the normative and policy-imposed constraints experienced by women in 2020 with regard to paid and unpaid labor, mental health, access to healthcare services, and government representation and consideration of women. These findings highlight women's varied and gendered experiences of the COVID-19 pandemic and emphasizes the role that government can proactively play in attending to gender inequalities throughout its COVID-19 response.

Evaluation of the effects of COVID-19 on pregnancy, fetus and newborn, and treatment management

Objective:

During pregnancy, changes occur in many systems, including the immune system. In line with our experience in the previous years, COVID-19 infections have negative effects on pregnancy. In our study, it was aimed to evaluate the effects of COVID-19 on pregnancy, fetus and newborn, and treatment management.

Methods:

In our study, 63 patients followed up between April 1, 2020 and April 1, 2021, were evaluated. Demographic data, symptoms, laboratory data, treatments, clinical course and delivery characteristics of the patients, as well as pathologies in the fetus and newborn were investigated retrospectively. The obtained data were statistically analyzed with Statistical Package for the Social Sciences.

Results:

In this study, 63 pregnant COVID-19 patients aged 19–37 years were included in the study. Fifty of the patients had symptoms of COVID-19 at the time of admission. At the time of admission, 13 patients required oxygen, and ten of these patients had severe radiological involvement. Seven patients were admitted to the intensive care unit, and three of them required invasive mechanical ventilation and deceased afterward. All newborns were found negative for the COVID-19 polymerase chain reaction test. Low birth weight has been detected in eight newborns and low Apgar score in 2 of them. Respiratory distress was observed in four newborns and they were discharged from intensive.

Conclusion:

Pregnant women have more disadvantages in the course of COVID-19 and have worse maternal outcomes. In addition, treatments such as Lopinavir/Ritonavir and hydroxychloroquine did not have any effect. These patients should be carefully evaluated and followed up.

Adequacy of Antenatal Care during the COVID-19 Pandemic: Observational Study with Postpartum Women

OBJECTIVE

 The present study aimed to evaluate the antenatal care adequacy for women who gave birth at the University Hospital of Santa Catarina in Florianopolis (Brazil) during the COVID-19 pandemic, and to evaluate the association of adequacy with sociodemographic, clinical, and access characteristics.

METHODS

 Data were collected between October and December 2020, including 254 patients who delivered in the University Hospital from Federal University of Santa Catarina and answered our questionnaires. Additional data were obtained from patients' antenatal booklets. Antenatal care was classified as adequate, intermediate, or inadequate according to the number of appointments, gestational age at the beginning of follow-up, and tests results. We carried out a descriptive statistical analysis and a bivariate/with odds ratio analysis on maternal sociodemographic, clinical and health access variables that were compared with antenatal adequacy.

RESULTS

 Antenatal care was considered adequate in 35.8% of cases, intermediate in 46.8%, and inadequate in 17.4%. The following maternal variables were associated with inadequate prenatal care (intermediate or inadequate prenatal care): having black or brown skin colour, having two or more children, being of foreign nationality, not being fluent in Portuguese, and using illicit drugs during pregnancy; the clinical variables were more than 6 weeks between appointments, and not attending high-risk antenatal care; as for access, the variables were difficulties in attending or scheduling appointments, and attending virtual appointments only.

CONCLUSION

 In a sample of pregnant women from a teaching hospital in Florianópolis during the COVID-19 pandemic, antenatal care was considered adequate in 35.8%, intermediate in 46.8%, and inadequate in 17.4% of cases.

Maternal mortality associated with COVID-19 in Brazil in 2020 and 2021: Comparison with non-pregnant women and men

OBJECTIVE

Mortality rates of pregnant and postpartum women grew in the second COVID-19 pandemic year. Our objective is to understand this phenomenon to avoid further deaths.

METHODS

We collected data from SIVEP-Gripe, a nationwide Brazilian database containing surveillance data on all severe acute respiratory syndrome caused by COVID-19, between the first notified case (February 2020) until the 17th epidemiological week of 2021. We stratified patients into maternal women (which includes pregnant and postpartum women), non-maternal women and men and divided them by time of diagnosis in two periods: first period (February to December 2020) and second period (the first 17 epidemiological weeks of 2021 before pregnant and postpartum women were vaccinated).

RESULTS

During the second period, all patients had higher risk of presenting severe COVID-19 cases, but the maternal population was at a higher risk of death (OR of 2.60 CI 95%: 2.28-2.97)-almost double the risk of the two other groups. Maternal women also had a higher risk of needing intensive care, intubation and of presenting desaturation in the second period. Importantly, maternal women presented fewer comorbidities than other patient groups, suggesting that pregnancy and postpartum can be an important risk factor associated with severe COVID-19.

CONCLUSION

Our results suggest that the Gama variant, which has been related to greater virulence, transmissibility and mortality rates leads to more severe cases of COVID-19 for pregnant and postpartum women.

COVID-19 outcomes among pregnant and nonpregnant women at reproductive age in Egypt

BACKGROUND

To describe demographic, clinical and epidemiological characteristics of pregnant and nonpregnant women with confirmed COVID-19 at reproductive age and determine risk factors of COVID-19 severe outcomes during pregnancy.

METHODS

A retrospective study for females aged 18-49 with confirmed COVID-19 by RT-PCR in Egypt, February-July 2020. Data were obtained from Egypt National Surveillance, bivariate and multivariate analysis for demographic and clinical characteristics and outcomes of COVID-19 between pregnant and nonpregnant women including ICU admission, need for ventilator and death was performed.

RESULTS

A total of 23 095 females were identified, with mean (SD) age of 35.1 (8.1) year. Of those, 408 (1.8%) were pregnant, with mean (SD) age of 29.3 (8.1) years. Compared to nonpregnant, pregnant patients were more likely to be admitted to hospital (OR = 1.7 CI = 1.4-2.1), ICU (OR = 2.4, CI = 1.3-4.3), need ventilator (OR = 3.9, CI = 2.1-7.4) and have severe outcome (OR = 3.0, CI = 1.9-4.7). Factors associated with severe outcome included: pregnancy, age > 30 years, underlying medical conditions, and living in rural areas.

CONCLUSION

Pregnant women with COVID-19 are at higher risk of severe symptoms and outcome including ICU admission, requiring ventilator and death. To reduce risk of severe outcome, counseling about for seeking medical care and health education about COVID-19 preventive measures should be performed.

Susceptibility to COVID-19 in Pregnancy, Labor, and Postpartum Period: Immune System, Vertical Transmission, and Breastfeeding

The new coronavirus (SARS-Cov-2) was first identified in late 2019 as the new RNA virus in the coronaviridae family responsible for causing COVID-19 in the residents of China's Hubei province. In mid-March 2020 WHO declared the pandemic caused by this virus as a result of thousands of people infected all over the world. Epidemiological evidence obtained from other pandemics, such as influenza and ebola, suggest that pregnant women are more susceptible to serious complications and death from viral infection. Physiological changes in the anatomical structure of the respiratory system as well as in the immune system during the pregnancy-puerperal period seem to contribute to this greater risk. Thus, pregnant women are more susceptible to be infected by the SARS-COV-2 or other viruses and to have serious COVID-19 disease. In fact, COVID-19 can alter immune responses at the maternal-fetal interface, affecting the well-being of both mother and her fetus. There is still no sufficient evidence in the literature to support the occurrence of vertical transmission and through breastfeeding, but the prevalence of prematurity was high among pregnant women infected by SARS-Cov-2. In this review, the changes in the immune system that may increase susceptibility to SARS-Cov-2 are discussed as well as the possible mechanisms involved in the transmission of the virus to the fetus by vertical transmission and during breastfeeding.

Vertical transmission of maternal COVID-19 antibodies after CoronaVac vaccine: A case report

The use of coronavirus disease 2019 RNA vaccines in pregnant women led to reports on the first cases of newborns with antibodies to sudden acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a phenomenon that was unknown when using immunizations with inactivated viruses. Thus, this study aimed to report a case of passive anti-SARS-CoV-2 immunity in a newborn through immunoprophylaxis of a pregnant woman who received the CoronaVac® vaccine in the third trimester of pregnancy. Twenty-four hours after delivery, samples were collected from the newborn and screened by enzyme immunoassays, which revealed antibodies to SARS-CoV-2.

Planned home birth assistance: challenges during the COVID-19 pandemic

OBJECTIVE

To understand the challenges faced by urban midwives in assisting planned home births during the COVID-19 pandemic.

METHODS

Qualitative study, based on the Collective Subject Discourse methodological framework, carried out with eight professionals, members of a birth care collective from the northeast region of Brazil. Data was collected between September and October of 2020 using the focus group technique.

RESULTS

The collective discourses revealed five central ideas: Changing assistance strategy; Dealing with frustration; Facing the fear of contamination; Avoiding exposure to the virus; and Keeping distance during the care process.

FINAL CONSIDERATIONS

The challenging condition the pandemic brings to the care of planned home births is made evident, being marked by the need for collective protection and the pressure of following health recommendations. The study also points out the need for official protocols and good quality information based on scientific evidence and humanizing principles to guide health care.

No COVID-19 Cases Detected Between April and September 2020 After Screening All 838 Admissions to a Maternity Unit in Poland

BACKGROUND Between April and September 2020, there were <10 000 reported cases of COVID-19 in the Masovia district, Poland, and <1000 new cases daily in Poland. During this period, all new hospital admissions to a maternity unit of a teaching hospital in Warsaw were screened for the COVID-19 infection. This retrospective study presents the findings from the reverse transcription-polymerase chain reaction (RT-PCR) test for COVID-19. MATERIAL AND METHODS This study included 838 women admitted for delivery between April 20 and September 20, 2020. All the admitted women were assigned to a low-risk or a high-risk group for COVID-19 and underwent RT-PCR nasopharyngeal swab tests (GeneFinder™-COVID-19-Plus-RealAmpKit. OSANG Healthcare Co., Ltd., Gyeonggi-do, Korea) for COVID-19. The testing protocol included repeated testing in case of inconclusive results or negative results in the symptomatic patients. The maternal and neonatal data from these cases were collected and analyzed. RESULTS All of the 838 women tested negative for COVID-19. Two women (0.24%) were classified as high risk for COVID-19. For 4 (0.48%) women, the results were initially inconclusive and negative when repeated. One hundred and eighty-one (21.5%) women presented with comorbidities, and 60 (7.2%) women were ≥40 years old. CONCLUSIONS The findings from this study show that between April and September 2020, there were no cases of COVID-19 infections at the maternity unit of a teaching hospital in Warsaw, Poland. However, the infection rates for COVID-19 across Europe continue to change. Testing protocols have been developed and established for all hospital admissions and it is anticipated that testing methods will become more rapid and accurate.

Prognosis and Outcomes of COVID-19 infection During Pregnancy

The pathophysiology of COVID-19 and pregnancy physiology intertwine in mysterious ways; thus, studying outcomes and prognosis in pregnant women with this new disease is an emerging concern. In this chapter, two main parts are presented; the first part discusses the effect of pregnancy on COVID-19, whether pregnant women are more susceptible to the disease, the different course of the disease and its severity in the pregnant population compared with the general population, and specific reference to COVID-19 complications in pregnant women. Also, the need for hospitalization, intensive care, and mechanical ventilation is reviewed. On the other hand, the second part of the chapter presents the effect of COVID-19 on pregnancy and discusses different maternal, fetal, and neonatal morbidities, including the possibility of vertical transmission, which could be caused by COVID-19 in this vulnerable group. Furthermore, maternal and perinatal mortality rates are discussed.

Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis

OBJECTIVE

To describe clinical characteristics of pregnant and postpartum women with severe COVID-19 in Brazil and to examine risk factors for mortality.

DESIGN

Cross-sectional study based on secondary surveillance database analysis.

SETTING

Nationwide Brazil.

POPULATION OR SAMPLE

978 Brazilian pregnant and postpartum women notified as COVID-19 Acute Respiratory Distress Syndrome (ARDS) cases with complete outcome (death or cure) up to 18 June 2020.

METHODS

Data was abstracted from the Brazilian ARDS Surveillance System (ARDS-SS) database. All eligible cases were included. Data on demographics, clinical characteristics, intensive care resources use and outcomes were collected. Risk factors for mortality were examined by multivariate logistic regression.

MAIN OUTCOME MEASURES

Case fatality rate.

RESULTS

We identified 124 maternal deaths, corresponding to a case fatality rate among COVID-19 ARDS cases in the obstetric population of 12.7%. At least one comorbidity was present in 48.4% of fatal cases compared with 24.9% in survival cases. Among women who died, 58.9% were admitted to ICU, 53.2% had invasive ventilation and 29.0% had no respiratory support. The multivariate logistic regression showed that the main risk factors for maternal death by COVID-19 were being postpartum at onset of ARDS, obesity, diabetes and cardiovascular disease, whereas white ethnicity had a protective effect.

CONCLUSIONS

Negative outcomes of COVID-19 in this population are affected by clinical characteristics but social determinants of health also seem to play a role. It is urgent to reinforce containment measures targeting the obstetric population and ensure high quality care throughout pregnancy and the postpartum period.

TWEETABLE ABSTRACT

A total of 124 COVID-19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors.

Risk factors for adverse outcomes among pregnant and postpartum women with acute respiratory distress syndrome due to COVID-19 in Brazil

OBJECTIVE

To evaluate whether clinical and social risk factors are associated with negative outcomes for COVID-19 disease among Brazilian pregnant and postpartum women.

METHODS

A secondary analysis was conducted of the official Acute Respiratory Syndrome Surveillance System database. Pregnant and postpartum women diagnosed with COVID-19 ARDS until July 14, 2020, were included. Adverse outcomes were a composite endpoint of either death, admission to the intensive care unit (ICU), or mechanical ventilation. Risk factors were examined by multiple logistic regression.

RESULTS

There were 2475 cases of COVID-19 ARDS. Among them, 23.8% of women had the composite endpoint and 8.2% died. Of those who died, 5.9% were not hospitalized, 39.7% were not admitted to the ICU, 42.6% did not receive mechanical ventilation, and 25.5% did not have access to respiratory support. Multivariate analysis showed that postpartum period, age over 35 years, obesity, diabetes, black ethnicity, living in a peri-urban area, no access to Family Health Strategy, or living more than 100 km from the notification hospital were associated with an increased risk of adverse outcomes.

CONCLUSION

Clinical and social risk factors and barriers to access health care are associated with adverse outcomes among maternal cases of COVID-19 ARDS in Brazil.