COVID-19 poses alarming pregnancy and postpartum mortality risk in Brazil

Abstract

As of April 14, 2021, there have been over 2·9 million COVID-19-related deaths worldwide; a disproportionate number of these are among socially marginalized populations. The combined risk of COVID-19 and pregnancy is a concern, particularly for racial and ethnic groups that experience worse outcomes from both conditions due to upstream social determinants of health and systemic racism. [[1]Minkoff H. You don't have to be infected to suffer: COVID-19 and racial disparities in severe maternal morbidity and mortality.Am J Perinatol. 2020; 37: 1052-1054Crossref PubMed Scopus (21) Google Scholar] While early on in the pandemic, pregnancy was not considered a risk factor, research is evolving and recent studies have demonstrated that pregnant people with COVID-19 are at increased risk for adverse outcomes, including death. [2Kotlar B. Gerson E. Petrillo S. Langer A. Tiemeier H. The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review.Reprod Health. 2021; 18: 10Crossref PubMed Scopus (298) Google Scholar, 3Zambrano L.D. Ellington S. Strid P. et al.Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status — United States, January 22–October 3, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69https://doi.org/10.15585/mmwr.mm6944e3Crossref Google Scholar, 4Nakamura-Pereira M. Knobel R. Menezes M.O. Andreucci C.B. Takemoto M.L.S. The impact of the COVID-19 pandemic on maternal mortality in Brazil: 523 maternal deaths by acute respiratory distress syndrome potentially associated with SARS-CoV-2.Int J Gynecol Obstet. 2021; 00: 1-2https://doi.org/10.1002/ijgo.13643Crossref Scopus (7) Google Scholar] Furthermore, previous research from Brazil showed racial inequalities in maternal mortality, with deaths among Black women documented at almost two times higher than White women as of July 2020. [[5]de Souza Santos D. de Oliveira Menezes M. Andreucci C.B. et al.Disproportionate impact of coronavirus disease 2019 (COVID-19) among pregnant and postpartum black women in Brazil through structural racism lens.Clin Infect Dis. 2020; (published online July 28)https://doi.org/10.1093/cid/ciaa1066Crossref Scopus (27) Google Scholar] Brazil reported a disproportionately large number of maternal deaths attributed to COVID-19, particularly during the postpartum period. Data from the Brazilian Ministry of Health's Influenza Epidemiological Surveillance Information System (SIVEP-Gripe, publicly available at https://opendatasus.saude.gov.br/dataset/bd-srag-2020), showed that, as of December 6, 2020, there were 160 notified deaths associated with COVID-19 among pregnant and 106 deaths among postpartum hospitalized women (Table 1). Furthermore, when combining pregnant and postpartum deaths, the in-hospital fatality rate was 8·3% (6·7% among White women, and 11·1% among Black women).Table 1OutcomesaThese results should be interpreted with caution, due to the high rate of incomplete reporting in the U.S. of Black and White pregnant & postpartum women hospitalized with laboratory-confirmed COVID-19 in the U.S. and BrazilbFor the U.S., we conservatively included data on all deaths (hospitalized or not) because the report did not differentiate between them. [6] We assume that most cases that resulted in death would have been severe enough to be hospitalized. For the denominator, we consider only the cases that were hospitalized. For Brazil, we present only hospitalizations with a recorded outcome (discharged or death). However, data from the U.S. include those missing an outcome (which constitutes almost half of pregnant women and 21% of nonpregnant women, who were assumed to have survived). [6] Missingness of this variable is improving and was reduced to 22% for pregnant women and 17% for nonpregnant women in an updated report released in November. [3] This updated report was not included in the table because although it included the number of deaths, it did not disaggregate cases by hospitalization status, and therefore we were not able to calculate rates comparable with Brazil's in-hospital case-fatality. The Centers for Disease Control and Prevention (CDC) indicates as of April 12, 2021, there have been 95 deaths among pregnant women and 14,434 hospitalizations; data were not available to distinguish between hospitalizations indicated by respiratory illness and labor/delivery. [10].Total (Black, White, Other, and NR)cNR = not reported. Other race in CDC data includes Hispanic or Latino, Asian non-Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Other Pacific Islander. In Brazil, it includes Indigenous, Brown, and Asian. Comparable information is not widely available in the U.S.BlackdFor the U.S. data, Black categories represent Black, non-Hispanic and the White category represents, White, non-Hispanic.WhitedFor the U.S. data, Black categories represent Black, non-Hispanic and the White category represents, White, non-Hispanic.PostpartumBrazil – December 6n = 685n = 36n = 195 Death106 (15·5%)10 (27·8%)28 (14·4%) ICU Admission228 (33·3%)17 (47·2%)57 (29·2%) Invasive Ventilation119 (17·4%)9 (25·0%)26 (13·3%)PregnantBrazil – December 6n = 2522n = 146n = 822 Death160 (6·3%)10 (6·9%)40 (4·9%) ICU Admission490 (19·4%)32 (21·9%)171 (20·8%) Invasive Ventilation178 (7·1%)11 (7·5%)54 (6·6%)U.S. – June 7n = 2587n = 461n = 492 Death16 (0·6%)6 (1·3%)<5 (<1·1%)eCell counts <5 were suppressed. ICU Admission120 (4·6%)28 (6·1%)12 (2·4%) Invasive Ventilation42 (1·6%)9 (2·0%)<5 (<1·1%)eCell counts <5 were suppressed.Non-Pregnant/Non-PostpartumBrazil – December 6n = 34,469n = 1590n = 13,410 Death4812 (14·0%)294 (18·5%)1554 (11·6%) ICU Admission8548 (24·8%)423 (26·6%)3440 (25·7%) Invasive Ventilation3763 (10·9%)212 (13·3%)1406 (10·5%)U.S. – June 7n = 4808n = 1119n = 803 Death208 (4·3%)74 (6·6%)37 (4·6%) ICU Admission757 (15·7%)194 (17·3%)158 (19·7%) Invasive Ventilation225 (4·7%)48 (4·3%)44 (5·5%)a These results should be interpreted with caution, due to the high rate of incomplete reporting in the U.S.b For the U.S., we conservatively included data on all deaths (hospitalized or not) because the report did not differentiate between them. [6]Ellington S. Strid P. Tong V.T. 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: 769-775Crossref PubMed Scopus (0) Google Scholar We assume that most cases that resulted in death would have been severe enough to be hospitalized. For the denominator, we consider only the cases that were hospitalized. For Brazil, we present only hospitalizations with a recorded outcome (discharged or death). However, data from the U.S. include those missing an outcome (which constitutes almost half of pregnant women and 21% of nonpregnant women, who were assumed to have survived). [6]Ellington S. Strid P. Tong V.T. 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: 769-775Crossref PubMed Scopus (0) Google Scholar Missingness of this variable is improving and was reduced to 22% for pregnant women and 17% for nonpregnant women in an updated report released in November. [3]Zambrano L.D. Ellington S. Strid P. et al.Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status — United States, January 22–October 3, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69https://doi.org/10.15585/mmwr.mm6944e3Crossref Google Scholar This updated report was not included in the table because although it included the number of deaths, it did not disaggregate cases by hospitalization status, and therefore we were not able to calculate rates comparable with Brazil's in-hospital case-fatality. The Centers for Disease Control and Prevention (CDC) indicates as of April 12, 2021, there have been 95 deaths among pregnant women and 14,434 hospitalizations; data were not available to distinguish between hospitalizations indicated by respiratory illness and labor/delivery. [10]CDC (Centers for Disease Control and Prevention)Data on COVID-19 during pregnancy: severity of maternal illness.Cent Dis Control Prev. 2021; (published online April 14) (accessed April 14, 2021)https://covid.cdc.gov/covid-data-trackerGoogle Scholarc NR = not reported. Other race in CDC data includes Hispanic or Latino, Asian non-Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Other Pacific Islander. In Brazil, it includes Indigenous, Brown, and Asian. Comparable information is not widely available in the U.S.d For the U.S. data, Black categories represent Black, non-Hispanic and the White category represents, White, non-Hispanic.e Cell counts <5 were suppressed. Open table in a new tab These findings are stark in comparison to the U.S. data on hospital deaths, intensive care unit (ICU) admissions, and invasive mechanical ventilation according to limited data presented in a Centers for Disease Control and Prevention (CDC) report (Table 1). [[6]Ellington S. Strid P. Tong V.T. 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: 769-775Crossref PubMed Scopus (0) Google Scholar] Black women fare worse in Brazil and the U.S. than their White counterparts, however, maternal outcomes are overall worse in Brazil regardless of race. In Brazil, racial disparities in maternal mortality existed even before the pandemic, where deaths among Black, Brown, and Indigenous women accounted for a disproportionate amount of maternal deaths, [[7]Martins A.L. Maternal mortality among black women in Brazil.Cad Saude Publica. 2006; 22: 2473-2479Crossref PubMed Google Scholar] and these women also received worse prenatal care. [[8]Leal M do C. Gama S.G.N. Pereira A.P.E. et al.A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil.Cad Saúde Pública. 2017; 33https://doi.org/10.1590/0102-311x00078816Crossref Google Scholar] Brazil's high maternal in-hospital fatality rates need to be mitigated. As demonstrated in Table 1, postpartum women in Brazil with COVID-19 have died at even higher rates than pregnant women, yet this population remains understudied. The high maternal death rates in Brazil are accompanied by large racial, geographic, and socioeconomic disparities. Within Brazil, special attention needs to be given to pregnant and postpartum people and particularly those who are Black, Indigenous, and People of Color. Both upstream social and economic policies, as well as downstream hospital care, would benefit from adopting this contextual lens. It is important to note that the hospitalized deaths account for only a portion of the impact that COVID-19 will have on maternal mortality. Previous research has demonstrated the number of reported severe acute respiratory illness (SARI) maternal deaths classified as non-defined in the SIVEP-Gripe system in 2020 is 1.5 times that of SARI maternal deaths due to all respiratory causes in 2016. [[4]Nakamura-Pereira M. Knobel R. Menezes M.O. Andreucci C.B. Takemoto M.L.S. The impact of the COVID-19 pandemic on maternal mortality in Brazil: 523 maternal deaths by acute respiratory distress syndrome potentially associated with SARS-CoV-2.Int J Gynecol Obstet. 2021; 00: 1-2https://doi.org/10.1002/ijgo.13643Crossref Scopus (7) Google Scholar] Additionally, the data presented in Table 1 does not include maternal deaths among those who do not have COVID-19 but whose care is compromised or limited by overstretched health system capacity. [[2]Kotlar B. Gerson E. Petrillo S. Langer A. Tiemeier H. The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review.Reprod Health. 2021; 18: 10Crossref PubMed Scopus (298) Google Scholar] Finally, the mental and physical stress of remaining at home during lockdowns and increased social isolation that occurred in many countries may compromise mental health and increase rates of intimate partner violence. [[2]Kotlar B. Gerson E. Petrillo S. Langer A. Tiemeier H. The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review.Reprod Health. 2021; 18: 10Crossref PubMed Scopus (298) Google Scholar] It is unknown if these trends of postpartum deaths are truly specific to Brazil or if other countries may also be experiencing such alarming outcomes among COVID-19 positive patients. When evidence is sparse, policymaking is compromised. Current understanding of the relationship between COVID-19 and pregnancy is informed by evidence from single- or multi-site studies where pregnancy/postpartum status of cases is reported, with varied quality, and population-level insights cannot be made. Consequently, incomplete data may have contributed to the delay in identifying pregnancy as a risk factor for severe illness with COVID-19. Detailed data availability across a variety of global contexts is imperative, as health systems that do not consistently collect pregnancy and postpartum status on COVID-19 case reports are likely to undercount adverse maternal outcomes. The United Nations Sustainable Development Goal 3 includes a target of reducing global maternal mortality to less than 70 per 100,000 live births by 2030. [[9]United Nations. Sustainable Development Goal 3. U. N. - Dep. Econ. Soc. Aff. n.d. https://sdgs.un.org/goals/goal3 (accessed April 13, 2021).Google Scholar] We are at further risk of not meeting this goal if we fail to identify and mitigate the intersecting effects of COVID-19 and racism on maternal health inequities. The authors have nothing to disclose.

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