Since the first outbreak of COVID-19 was reported in December 2019 in Wuhan, China, the disease has spread rapidly around the world, prompting the World Health Organization (WHO) to declare a health emergency. public of international importance on January 30, 2020 through December 12, 2021, more than 269 million infections and 5.3 million deaths from COVID-19 had been reported worldwide.
Pregnant and postpartum women are generally more susceptible to developing serious viral infections due to physiological adaptations that occur during pregnancy. In previous coronavirus epidemics of severe acute respiratory distress syndrome virus and Middle East respiratory syndrome virus, pregnant women had higher case fatality rates and more complications than non-pregnant women.
Based on data from the first five months of the COVID-19 pandemic, some reports suggested that pregnant women were not at increased risk of significant adverse outcomes in SARS-CoV-2 infections. Furthermore, maternal mortality rates due to SARS-CoV-2 appear to have remained, at least initially, in line with pre-pandemic levels, with the course of the disease being primarily benign.
Unlike those early studies, subsequent analysis revealed that infected pregnant women were more likely to be admitted to intensive care, receive invasive ventilation, extracorporeal membrane oxygenation treatment, and die compared to non-pregnant women of reproductive age.
Currently, of the few studies from low- and middle-income countries that compare levels and trends in maternal mortality, before and during the COVID-19 pandemic, an increase in maternal deaths was found. There are two hypothetical pathways by which maternal mortality levels could change: either by worsening of SARS-CoV-2 infection due to pregnancy status or by disruptions in access to maternity services.
As of late March 2021, several countries in the Americas reported a significant number of maternal deaths related to COVID-19. A partial snapshot of the situation in Latin America (LAC) as of June 15, 2020 showed more than 100 maternal deaths related to COVID-19 out of a total of 2,291 pregnant women who tested positive for SARS-CoV-2 from six LAC countries .
Identifying the characteristics that can lead to death is essential in pregnant and postpartum women with COVID-19. Therefore, this study aims to describe and analyze the clinical and epidemiological characteristics of maternal deaths associated with COVID-19 recorded in a multi-country collaborative database in Latin America.
Background
This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a Latin American multi-country collaborative database.
Methods
This was an observational study implemented from March 1, 2020 to November 29, 2021 in eight Latin American countries. The information was based on the Perinatal Information System of the Latin American Center for Perinatology, Women’s and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables as medians with interquartile ranges.
Results
- A total of 447 deaths were identified.
- The median maternal age was 31 years.
- 86.4% of women were infected before childbirth, and the majority of cases (60.3%) were detected in the third trimester of pregnancy.
- The most frequent symptoms at the first consultation and admission were dyspnea (73.0%), fever (69.0%) and cough (59.0%).
- Organ dysfunction was reported in 90.4% of women during admission. A total of 64.8%
of women were admitted to intensive care for a median of eight days.
- In most cases, death occurred during the postpartum period, with a median of seven days between delivery and death.
- Preterm birth was the most common perinatal complication (76.9%) and 59.9% were low birth weight.
In conclusion , the present study provides valuable information on the presentation of maternal mortality associated with COVID-19 among women in LAC. Additionally, we found health barriers that pregnant women in LAC face in accessing intensive care services. Decision makers should strengthen severity awareness and referral strategies to avoid potential delays in care for obstetric patients.
We also recommend increasing the capacity to care for seriously ill maternal patients in LAC countries, especially by defining protocols and expanding critical care beds according to the needs of the Latin American country.
Interpretation
This study describes the characteristics of maternal deaths in a comprehensive database from several countries in Latin America during the COVID-19 pandemic. The barriers that Latin American pregnant women face in accessing intensive care services when they require it were also revealed. Decision makers should strengthen severity awareness and referral strategies to avoid potential delays.
Evidence before this study
Despite millions of infections and deaths associated with COVID-19 worldwide, few maternal deaths related to SARS-CoV-2 infection have been reported. We searched PubMed (“obstetric” OR “maternal”) AND (“death” OR “mortality”) AND (“COVID-19” OR “coronavirus”) from inception to March 26, 2022.
The selection criteria were observational studies that evaluated maternal mortality associated with COVID-19. We added a filter for women’s studies. We found 786 articles, of which 53 were observational studies reporting maternal outcomes. The study that reported the highest number of maternal deaths was conducted in Brazil (1,031 deaths), followed by a study in Mexico (309 deaths) and South Africa (39 deaths).
Added value of this study
We found 447 maternal deaths associated with COVID-19, with around 90% of all cases with an identified cause of death related to acute respiratory failure following severe COVID-19 infection. We show that 35% of maternal deaths associated with COVID-19 were not admitted to critical care.
Implications of all available evidence
We found that almost half of maternal deaths associated with COVID-19 were infected during the third trimester.
About half of the pregnant women who died were obese and about a quarter were 35 years old or older.
We found that a significant percentage of maternal deaths in women with COVID-19 were directly related to acute respiratory failure and about a third were not admitted to the ICU.
Efforts should be directed at increasing awareness for early detection of the severity of COVID-19 in the pregnant population across the region.
Funds: Latin American Center for Perinatology, Women’s and Reproductive Health.
