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Manca TA, Top KA, Graham JE. COVID-19 vaccination in pregnancy: How discrepant public health discourses shape responsibility for fetal health. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 3:100265. [PMID: 37069999 PMCID: PMC10084631 DOI: 10.1016/j.ssmqr.2023.100265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/16/2023] [Accepted: 04/08/2023] [Indexed: 04/19/2023]
Abstract
Early in COVID-19 vaccine rollout, expert recommendations about vaccination while pregnant and breastfeeding changed rapidly. This paper addresses the (re)production of gendered power relations in these expert discourses and recommendations in Canada. We collected texts about COVID-19 vaccine use in pregnancy (N = 52) that Canadian health organizations (e.g., professional societies, advisory groups, health authorities) and vaccine manufacturers made publicly available online. A discourse analysis was undertaken to investigate intertextuality (relations between texts), social construction (incorporation of assumptions about gender), and contradictions between and within texts. National expert recommendations varied in stating COVID-19 vaccines are recommended, should be offered, or may be offered, while manufacturer texts consistently stated there was no evidence. Provincial and territorial texts reproduced discrepancies between the Society of Obstetricians and Gynaecologists of Canada and National Advisory Committee on Immunization recommendations, including that COVID-19 vaccines should be versus may be offered in pregnancy. Our findings suggest gaps in data and discrepant COVID-19 vaccine recommendations, eligibility, and messaging limit guidance regarding vaccination in pregnancy. We argue that these discrepancies magnified the already common practice of deferring responsibility for the uncertainties of vaccination in pregnancy onto parents and healthcare providers. The deferral of responsibility could be reduced by harmonizing recommendations, regularly updating texts that describe evidence and recommendations, and prioritizing research into disease burden, vaccine safety, and efficacy before vaccine rollout.
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Affiliation(s)
- T A Manca
- Faculty of Health Disciplines, Athabasca University, 1 University Drive, Athabasca, Alberta, T9S 3A3, Canada
- Department of Sociology and Social Anthropology, Dalhousie University, Room 1128, Marion McCain Arts and Social Sciences Building, Halifax, Nova Scotia, B3H 4R2, Canada
| | - K A Top
- Department of Pediatrics (Infectious Diseases), Dalhousie University, 5850 University Avenue, P. O. Box 9700, Halifax, Nova Scotia, B3K 6R8, Canada
- Canadian Center for Vaccinology, IWK Health Centre, 5980 University Ave, Halifax, Nova Scotia, B3K 6R8, Canada
| | - J E Graham
- Department of Pediatrics (Infectious Diseases), Dalhousie University, 5850 University Avenue, P. O. Box 9700, Halifax, Nova Scotia, B3K 6R8, Canada
- Canadian Center for Vaccinology, IWK Health Centre, 5980 University Ave, Halifax, Nova Scotia, B3K 6R8, Canada
- Technoscience & Regulation Research Unit, Faculty of Medicine, 5849 University Avenue, C-301, Halifax, NS, B3H 4H7, Canada
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Waring ME, Pagoto SL, Rudin LR, Ho C, Horkachuck A, Kapoor IA, Foye Q. Factors associated with mothers' hesitancy to receive a COVID-19 vaccine. J Behav Med 2023; 46:179-184. [PMID: 34981306 PMCID: PMC8723796 DOI: 10.1007/s10865-021-00268-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/21/2021] [Indexed: 10/25/2022]
Abstract
Vaccine hesitancy can impact maternal and child vaccination rates. We examined factors associated with mothers' hesitancy to receive a COVID-19 vaccine using data from an online survey conducted from mid-February to mid-March 2021. Among unvaccinated participants (N = 203), 28% reported that they would probably not or definitely not get a COVID-19 vaccine. Mothers with high school/GED/trade/technical education (38% hesitant, aOR = 4.0, 95% CI: 1.2-13.2), Associate's degree (43%, aOR = 6.8, 95% CI: 2.4-19.5), and Bachelor's degree (30%, aOR = 3.1, 95% CI: 1.1-8.4) were more likely to report vaccine hesitancy compared to mothers with a graduate degree (19%). Non-Hispanic Black mothers (40% hesitant, aOR = 2.8, 95% CI: 1.0-7.6) were more likely to be vaccine hesitant compared to non-Hispanic white mothers (19%). Mothers with low pandemic-related anxiety were more likely to report vaccine hesitancy than mothers with high pandemic-related anxiety (56% vs 23% hesitant; aOR = 4.8, 95% CI: 1.7-14.1). Research is needed to understand informational, emotional, and attitudinal factors contributing to COVID-19 vaccine hesitancy among mothers to develop and test effective public health messaging to increase vaccination rates.
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Affiliation(s)
- Molly E Waring
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA.
| | - Sherry L Pagoto
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA
| | - Lauren R Rudin
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA
| | - Chloe Ho
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA
| | - Alexa Horkachuck
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA
| | - Indra A Kapoor
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA
| | - Quamyia Foye
- Department of Allied Health Sciences and UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Rd, Unit 1101, Storrs, CT, 06269, USA
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Chimukuche RS, Nkosi B, Seeley J. Policy and Guideline Review of Vaccine Safety for COVID-19 in Pregnant Women in Southern Africa, with a Particular Focus on South Africa. Vaccines (Basel) 2022; 10:vaccines10122077. [PMID: 36560487 PMCID: PMC9786044 DOI: 10.3390/vaccines10122077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Pregnant and lactating mothers have historically been excluded from clinical trials. To understand the shift from excluding to including this population in COVID-19 vaccine trials, we conducted a review of guidance issued by countries in southern Africa over the last three years. We conducted a review of documents and official statements recorded on Ministries of Health websites, and social media platforms, the World Health Organisation website, the COVID-19 Maternal Immunisation tracker and the African Union official webpage. Search terms included COVID-19 vaccination policies, guidelines for pregnant and lactating women, COVID-19 vaccination trials and pregnant women. We retrieved and reviewed policies, guidelines, and official statements from 12 countries. We found inconsistencies and incomplete guidance in respect to the inclusion of pregnant and lactating mothers in COVID-19 vaccine trials from the selected countries. Of the twelve countries reviewed, Namibia and South Africa had clear guidance on vaccination plans and implementation for pregnant women, and their inclusion in COVID-19 vaccine trials. Explicit and clear guidelines are critical in communicating changes in policy towards those deemed vulnerable for them to participate in vaccine trials. This review provides lessons for future pandemics on managing changes in guidance towards those groups historically excluded from vaccine and clinical trials.
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Affiliation(s)
- Rujeko Samanthia Chimukuche
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection & Immunity, University College London, London WC1E 6BT, UK
- Correspondence:
| | - Busisiwe Nkosi
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, KwaZulu-Natal, South Africa
- Department of Global Health and Development, London School of Tropical Hygiene and Medicine, London WC1H 9SH, UK
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Kouba I, Yaghoubian Y, Rochelson B, Shan W, Combs A, Nimaroff M, Blitz MJ. Acceptance of coronavirus disease 2019 vaccination among postpartum women during delivery hospitalization. J Matern Fetal Neonatal Med 2022; 35:10502-10505. [PMID: 36210157 DOI: 10.1080/14767058.2022.2131386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The immediate postpartum period, during delivery hospitalization, represents a unique opportunity to offer coronavirus disease 2019 (COVID-19) vaccination to those who did not previously receive it. In this study, we evaluated patient characteristics associated with acceptance of vaccination in this group. METHODS This retrospective cohort study evaluated all unvaccinated patients who were offered postpartum COVID-19 vaccination during delivery hospitalization between May 2021 and September 2021 at seven hospitals within a large integrated health system in New York. During the study period, each hospitalized, unvaccinated obstetrical patient was offered the vaccine prior to discharge. Patients with positive SARS-CoV-2 PCR testing during hospitalization were excluded. Medical records were reviewed to obtain sociodemographic characteristics and to confirm administration of COVID-19 vaccination. Multiple logistic regression was performed to model the probability of receiving postpartum vaccination. RESULTS A total of 8,281 unvaccinated postpartum patients were included for analysis and 412 (5%) received a COVID-19 vaccine before hospital discharge. Patients who received the vaccine were more likely to be older, have private insurance, decline to answer questions about religious affiliation, and deliver in the final two months of the study period. Likelihood of receiving postpartum vaccination was not affected by race-ethnicity, preferred language, marital status, parity, body mass index, or neighborhood socioeconomic conditions. Patients who declined vaccination were more likely to have positive SARS-CoV-2 antibody testing at delivery compared to those who received vaccination (49 vs. 29%; p < .001). CONCLUSION Only 5% of unvaccinated postpartum patients received a COVID-19 vaccine before hospital discharge. It is concerning that patients with public health insurance were less likely to receive vaccination. This may be due to variation in vaccine counseling or other unmeasured factors. Despite the low acceptance rate in our study population, COVID-19 vaccination should be offered in a variety of clinical settings to maximize opportunities for administration.
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Affiliation(s)
- Insaf Kouba
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Yasaman Yaghoubian
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Burton Rochelson
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Weiwei Shan
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Adriann Combs
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Michael Nimaroff
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Matthew J Blitz
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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Szalma I, Bitó T. Attitudes toward COVID-19 vaccination of pregnant and lactating women in Hungary. J Perinat Med 2022; 51:531-537. [PMID: 36398329 DOI: 10.1515/jpm-2022-0372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study has three purposes. First, we explore the percentage of the population that is vaccinated and the factors that contribute to whether or not an individual takes up COVID-19 vaccination. Second, we also look at how pregnant and lactating women (PLW) take up vaccination. Third, we reveal what the public think about PLW receiving vaccines. METHODS Questionnaire data collection was carried out online using the quota method among Hungarians aged 18-65 with Internet access. The survey was carried out between 29th November and 11th December 2021. A total of 1,000 participants completed the questionnaire. RESULTS A total of 66.4% of the respondents aged 18-65 received vaccination. There were significant differences across sociodemographic variables in vaccination: men and individuals with more education, better perceived financial status, and personal experience with COVID-19 were more likely to be vaccinated. PLW were less likely to be vaccinated, partly due to their fear of vaccines' side-effects. More than one third of the participants do not agree with PLW having COVID-19 vaccination. In general, attitudes toward vaccination of PLW differed significantly by social group. Men and individuals with tertiary education and better financial situation, who knew somebody who had died of COVID-19 infection, and who had been vaccinated were more likely to accept vaccination for both pregnant women and lactating mothers. CONCLUSIONS Acceptance of receiving COVID-19 vaccination depends on social status; thus, targeted campaigns are required. In addition, PLW are afraid of vaccines' side effects, so they should be provided information, just as there is a need to increase public information on this topic.
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Affiliation(s)
- Ivett Szalma
- "Momentum" Reproductive Sociology Researc Group, Centre for Social Sciences and Corvinus University of Budapest, Budapest, Hungary
| | - Tamás Bitó
- Department of Obstetrics and Gynaecology, University of Szeged, Szeged, Hungary
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Wang X, Tang K, Huang R, Yi S. COVID-19 vaccination status and associated factors among lactating women during the COVID-19 outbreak: a cross-sectional study in southern China. BMJ Open 2022; 12:e062447. [PMID: 36270762 PMCID: PMC9593106 DOI: 10.1136/bmjopen-2022-062447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Different countries and institutions around the world have debated whether lactating women should receive the COVID-19 vaccine during the COVID-19 pandemic. In China, lactating is not a contraindication to vaccination, but many women are still hesitant to get vaccinated. The purpose of this study was to investigate the current status of COVID-19 vaccination among lactating women and the related factors affecting vaccination. METHODS An online cross-sectional survey involving 506 lactating women was conducted in southern China. We explored the related factors affecting COVID-19 vaccination of lactating women from three aspects: general information, knowledge-attitude-behaviour towards COVID-19 and its vaccine, and postpartum psychological state. RESULTS A total of 432 lactating women completed the questionnaire, 198 of whom had received the COVID-19 vaccine. On the knowledge-attitude-behaviour questionnaire on COVID-19 and its vaccines, the vaccinated group scored higher than the unvaccinated group on both the three subdimensions of the questionnaire and the total score (p<0.01). The results of binary logistics regression analysis showed that mixed feeding (OR=2.68, 95% CI: 1.82 to 3.96), longer breastfeeding duration (OR=1.31, 95% CI: 1.16 to 1.49), better physical condition (OR=5.28, 95% CI: 1.82 to 15.32), higher attitude score of COVID-19 and its vaccine (OR=1.18, 95% CI: 1.10 to 1.27), and having a travel history in medium high-risk areas (OR=3.49, 95% CI: 1.46 to 8.37) were significantly associated with COVID-19 vaccination in lactating women. Having a master's degree or above (OR=0.03, 95% CI: 0.01 to 0.30), and having higher anxiety score (OR=0.66, 95% CI: 0.54 to 0.81) and depression score (OR=0.84, 95% CI: 0.75 to 0.93) were inversely associated with COVID-19 vaccination in lactating women. CONCLUSION 45.8% of lactating women were vaccinated against COVID-19. Education level, feeding methods, duration of breast feeding, travel history in medium high-risk areas, physical condition, attitude score of COVID-19 and its vaccine, anxiety symptom and depressive symptom score were associated with vaccination of lactating women. More interventions based on these factors were needed to reduce concerns for lactating women and increase their vaccination rates.
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Affiliation(s)
- Xiaofen Wang
- Department of Nursing, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Kun Tang
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Rong Huang
- Emergency Department, Changsha Central Hospital, Changsha, Hunan, China
| | - Simin Yi
- Department of Neurology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
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Laguila Altoé A, Marques Mambriz AP, Cardozo DM, Valentini Zacarias JM, Laguila Visentainer JE, Bahls-Pinto LD. Vaccine Protection Through Placenta and Breastfeeding: The Unmet Topic in COVID-19 Pandemic. Front Immunol 2022; 13:910138. [PMID: 35720385 PMCID: PMC9203883 DOI: 10.3389/fimmu.2022.910138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/09/2022] [Indexed: 01/10/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has turned pregnant women’s healthcare into a worldwide public health challenge. Although initial data did not demonstrate pregnancy as a more susceptible period to severe outcomes of acute severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) infection, there are an increasing number of reports showing that not only pregnant women might be at significantly higher risk than non-pregnant women by COVID-19 but also the fetus. These findings may be related to adaptive changes that occur during pregnancy, such as the reduction in the residual respiratory capacity, the decrease in viral immune responses, and the increased risk for thromboembolic events. Additionally, despite the SARS-CoV-2 vertical transmission evidence being uncommon, maternal illness severity might reflect serious perinatal and neonatal outcomes. Thus, protecting the maternal–fetal dyad against COVID-19 is critical. Even though pregnant women initially were excluded from vaccine trials, several studies have provided safety and efficacy of the overall vaccine COVID-19 platforms. Vaccination during pregnancy becomes a priority and can generate benefits for both the mother and newborn: maternal neutralizing antibodies are transmitted through the placenta and breastfeeding. Moreover, regarding passive immunization, human milk contains other bioactive molecules and cells able to modulate the newborn’s immune response, which can be amplified after the vaccine. Nonetheless, many issues remain to be elucidated, considering the magnitude of the protective immunity transferred, the duration of the induced immunity, and the optimal interval for pregnant immunization. In this review, we assessed these unmet topics supported by literature evidence regarding the vaccine’s immunogenicity, pregnancy immune heterogeneity, and the unique human milk antiviral features.
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Affiliation(s)
- Ariane Laguila Altoé
- Department of Basic Health Science, Laboratory of Immunogenetics, State University of Maringa, Maringa, Brazil
- Department of Medicine, State University of Maringa, Maringa, Brazil
| | - Anna Paula Marques Mambriz
- Department of Clinical Analysis and Biomedicine, Postgraduate Program in Biosciences and Physiopathology, State University of Maringa, Maringa, Brazil
| | | | - Joana Maira Valentini Zacarias
- Department of Basic Health Science, Laboratory of Immunogenetics, State University of Maringa, Maringa, Brazil
- Department of Clinical Analysis and Biomedicine, Postgraduate Program in Biosciences and Physiopathology, State University of Maringa, Maringa, Brazil
| | - Jeane Eliete Laguila Visentainer
- Department of Basic Health Science, Laboratory of Immunogenetics, State University of Maringa, Maringa, Brazil
- Department of Clinical Analysis and Biomedicine, Postgraduate Program in Biosciences and Physiopathology, State University of Maringa, Maringa, Brazil
| | - Larissa Danielle Bahls-Pinto
- Department of Basic Health Science, Laboratory of Immunogenetics, State University of Maringa, Maringa, Brazil
- *Correspondence: Larissa Danielle Bahls-Pinto,
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Scheler CA, Discacciati MG, Vale DB, Lajos GJ, Surita FG, Teixeira JC. Maternal Deaths from COVID-19 in Brazil: Increase during the Second Wave of the Pandemic. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:567-572. [PMID: 35649424 PMCID: PMC9948055 DOI: 10.1055/s-0042-1748975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare death rates by COVID-19 between pregnant or postpartum and nonpregnant women during the first and second waves of the Brazilian pandemic. METHODS In the present population-based evaluation data from the Sistema de Informação da Vigilância Epidemiológica da Gripe (SIVEP-Gripe, in the Portuguese acronym), we included women with c (ARDS) by COVID-19: 47,768 in 2020 (4,853 obstetric versus 42,915 nonobstetric) and 66,689 in 2021 (5,208 obstetric versus 61,481 nonobstetric) and estimated the frequency of in-hospital death. RESULTS We identified 377 maternal deaths in 2020 (first wave) and 804 in 2021 (second wave). The death rate increased 2.0-fold for the obstetric (7.7 to 15.4%) and 1.6-fold for the nonobstetric groups (13.9 to 22.9%) from 2020 to 2021 (odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.47-0.58 in 2020 and OR: 0.61; 95%CI: 0.56-0.66 in 2021; p < 0.05). In women with comorbidities, the death rate increased 1.7-fold (13.3 to 23.3%) and 1.4-fold (22.8 to 31.4%) in the obstetric and nonobstetric groups, respectively (OR: 0.52; 95%CI: 0.44-0.61 in 2020 to OR: 0.66; 95%CI: 0.59-0.73 in 2021; p < 0.05). In women without comorbidities, the mortality rate was higher for nonobstetric (2.4 times; 6.6 to 15.7%) than for obstetric women (1.8 times; 5.5 to 10.1%; OR: 0.81; 95%CI: 0.69-0.95 in 2020 and OR: 0.60; 95%CI: 0.58-0.68 in 2021; p < 0.05). CONCLUSION There was an increase in maternal deaths from COVID-19 in 2021 compared with 2020, especially in patients with comorbidities. Death rates were even higher in nonpregnant women, with or without comorbidities.
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Affiliation(s)
- Carlos André Scheler
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Michelle Garcia Discacciati
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Diama Bhadra Vale
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Giuliane Jesus Lajos
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Fernanda Garanhani Surita
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Julio Cesar Teixeira
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
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