The experience of pregnant women and their families who were infected with covid-19 before vaccination: A qualitative approach within a multicenter study in Brazil.

BACKGROUND: Pregnant and postpartum women infected by COVID-19 are at increased risk of adverse outcomes, including negative effects on their mental health. Brazilian maternal mortality rate due to COVID-19 is 2.5 times higher than overall mortality rates. This study aimed to understand how pregnant/postpartum women experienced the COVID-19 suspicion/investigation or confirmed infection in different Brazilian cities, the pandemic's consequences to women and their families, and their needs to improve maternal health services during public health emergencies. METHODS: We conducted a qualitative study with 27 women with COVID-19 and 6 of their family members, as part of a multicenter study among 15 maternity hospitals in Brazil. We applied in-depth interviews through telephone calls when women received the diagnostic or had a suspect infection and after 60 days. Another semi-structured interview was applied to their close family members. The interviews were considered through thematic analysis. RESULTS: From the thematic content analysis three major themes emerged from the first and second interviews: (Cucinotta and Vanelli, 2020) assistance received by the woman and newborn in the medical services; (World Health Organization (WHO) 2021) stigma/fear of contamination from health workers and from family and friends reported by the women; (Allotey et al., 2020) the COVID-19 pandemic impact. CONCLUSION: Before the availability of the COVID-19 vaccine, pregnant women experienced fear of death, hospitalization, quarantine, loss of family members, and financial repercussions, resulting in physical, psychological, and socioeconomic impacts on these women's lives.

The effect of body mass index on maternal and perinatal outcomes in COVID-19 infection during pregnancy and postpartum: Secondary analysis from the REBRACO cohort study.

OBJECTIVES: To compare maternal and perinatal outcomes among women with obesity, overweight, and normal body mass index, associated with COVID-19 infection during pregnancy and postpartum. METHOD: Prospective Cohort Study, within the REBRACO (Brazilian Network of COVID-19 in Pregnancy) multicenter initiative. Confirmed positive cases of SARS-CoV-2 were included, and women categorized into three groups according to their pre-pregnancy BMI: obesity (BMI ≥ 30), overweight (BMI <30 but >25), and normal BMI. Sociodemographic, clinical, and obstetric characteristics and different maternal and perinatal outcomes were compared, and a multiple regression analysis was performed to investigate factors independently associated with adverse maternal and perinatal outcomes. RESULTS: Two hundred eighty-nine women positive for SARS-CoV-2 infection were considered, and 202 had available data on maternal BMI for the current analysis. Overall, 72 (35.6%)obese, 68 (33.6%) overweight, and 60 (29.7%) normal BMI. Obesity was associated with increased adverse clinical outcomes including sepsis (P = 0.02), acute respiratory distress syndrome (P = 0.002), and the need for mechanical ventilation (P = 0.044). Considering perinatal outcomes, a multiple regression model confirmed obesity as an independent factor associated with adverse results (adjusted odds ratio 3.73, 95% CI 1.54-9.08). CONCLUSION: Obesity and overweight were associated with worse clinical outcomes, severe/critical COVID-19, and adverse perinatal outcomes.

Brazilian Black Women are at Higher Risk for COVID-19 Complications: An Analysis of REBRACO, a National Cohort.

OBJECTIVE: To evaluate the impact of the race (Black versus non-Black) on maternal and perinatal outcomes of pregnant women with COVID-19 in Brazil. METHODS: This is a subanalysis of REBRACO, a Brazilian multicenter cohort study designed to evaluate the impact of COVID-19 on pregnant women. From February 2020 until February 2021, 15 maternity hospitals in Brazil collected data on women with respiratory symptoms. We selected all women with a positive test for COVID-19; then, we divided them into two groups: Black and non-Black women. Finally, we compared, between groups, sociodemographic, maternal, and perinatal outcomes. We obtained the frequency of events in each group and compared them using X2 test; p-values < 0.05 were considered significant. We also estimated the odds ratio (OR) and confidence intervals (CI). RESULTS: 729 symptomatic women were included in the study; of those, 285 were positive for COVID-19, 120 (42.1%) were Black, and 165 (57.9%) were non-Black. Black women had worse education (p = 0.037). The timing of access to the health system was similar between both groups, with 26.3% being included with seven or more days of symptoms. Severe acute respiratory syndrome (OR 2.22 CI 1.17-4.21), intensive care unit admission (OR 2.00 CI 1.07-3.74), and desaturation at admission (OR 3.72 CI 1.41-9.84) were more likely to occur among Black women. Maternal death was higher among Black women (7.8% vs. 2.6%, p = 0.048). Perinatal outcomes were similar between both groups. CONCLUSION: Brazilian Black women were more likely to die due to the consequences of COVID-19.

OBJETIVO: Avaliar o impacto da raça (negra versus não negra) nos desfechos maternos e perinatais de gestantes com COVID-19 no Brasil. MéTODOS: Esta é uma subanálise da REBRACO, um estudo de coorte multicêntrico brasileiro desenhado para avaliar o impacto da COVID-19 em mulheres grávidas. De fevereiro de 2020 a fevereiro de 2021, 15 maternidades do Brasil coletaram dados de mulheres com sintomas respiratórios. Selecionamos todas as mulheres com teste positivo para COVID-19; em seguida, as dividimos em dois grupos: mulheres negras e não negras. Finalmente, comparamos, entre os grupos, os resultados sociodemográficos, maternos e perinatais. Obtivemos a frequência dos eventos em cada grupo e comparamos usando o teste X2; Valores de p < 0,05 foram considerados significativos. Também estimamos o odds ratio (OR) e os intervalos de confiança (IC). RESULTADOS: 729 mulheres sintomáticas foram incluídas no estudo; desses, 285 foram positivos para COVID-19, 120 (42,1%) eram negros e 165 (57,9%) não eram negros. As mulheres negras apresentaram pior escolaridade (p = 0,037). O tempo de acesso ao sistema de saúde foi semelhante entre os dois grupos, com 26,3% incluídos com sete ou mais dias de sintomas. Síndrome respiratória aguda grave (OR 2,22 CI 1,17­4,21), admissão em unidade de terapia intensiva (OR 2,00 CI 1,07­3,74) e dessaturação na admissão (OR 3,72 CI 1,41­9,84) foram mais prováveis de ocorrer entre mulheres negras. A mortalidade materna foi maior entre as negras (7,8% vs. 2,6%, p = 0,048). Os resultados perinatais foram semelhantes entre os dois grupos. CONCLUSãO: Mulheres negras brasileiras tiveram maior probabilidade de morrer devido às consequências da COVID-19.

Brazilian Black Women are at Higher Risk for COVID-19 Complications: An Analysis of REBRACO, a National Cohort / Mulheres negras brasileiras correm maior risco de complicações da COVID-19: uma análise do REBRACO, uma coorte nacional

Abstract Objective To evaluate the impact of the race (Black versus non-Black) on maternal and perinatal outcomes of pregnant women with COVID-19 in Brazil. Methods This is a subanalysis of REBRACO, a Brazilian multicenter cohort study designed to evaluate the impact of COVID-19 on pregnant women. From February2020 until February 2021, 15 maternity hospitals in Brazil collected data on women with respiratory symptoms. We selected all women with a positive test for COVID-19; then, we divided them into two groups: Black and non-Black women. Finally, we compared, between groups, sociodemographic, maternal, and perinatal outcomes. We obtained the frequency of events in each group and compared them using X2 test; p-values < 0.05 were considered significant. We also estimated the odds ratio (OR) and confidence intervals (CI). Results 729 symptomatic women were included in the study; of those, 285 were positive for COVID-19, 120 (42.1%) were Black, and 165 (57.9%) were non-Black. Black women had worse education (p = 0.037). The timing of access to the health system was similar between both groups, with 26.3% being included with seven or more days of symptoms. Severe acute respiratory syndrome (OR 2.22 CI 1.17-4.21), intensive care unit admission (OR 2.00 CI 1.07-3.74), and desaturation at admission (OR 3.72 CI 1.41-9.84) were more likely to occur among Black women. Maternal death was higher among Black women (7.8% vs. 2.6%, p = 0.048). Perinatal outcomes were similar between both groups. Conclusion Brazilian Black women were more likely to die due to the consequences of COVID-19.

Resumo Objetivo Avaliar o impacto da raça (negra versus não negra) nos desfechos maternos e perinatais de gestantes com COVID-19 no Brasil. Métodos Esta é uma subanálise da REBRACO, um estudo de coorte multicêntrico brasileiro desenhado para avaliar o impacto da COVID-19 em mulheres grávidas. De fevereiro de 2020 a fevereiro de 2021, 15 maternidades do Brasil coletaram dados de mulheres com sintomas respiratórios. Selecionamos todas as mulheres com teste positivo para COVID-19; em seguida, as dividimos em dois grupos: mulheres negras e não negras. Finalmente, comparamos, entre os grupos, os resultados sociodemográficos, maternos e perinatais. Obtivemos a frequência dos eventos em cada grupo e comparamos usando o teste X2; Valores de p <0,05 foram considerados significativos. Também estimamos o odds ratio (OR) e os intervalos de confiança (IC). Resultados 729 mulheres sintomáticas foram incluídas no estudo; desses, 285 foram positivos para COVID-19, 120 (42,1%) eram negros e 165 (57,9%) não eram negros. As mulheres negras apresentaram pior escolaridade (p = 0,037). O tempo de acesso ao sistema de saúde foi semelhante entre os dois grupos, com 26,3% incluídos com sete ou mais dias de sintomas. Síndrome respiratória aguda grave (OR 2,22 CI 1,17-4,21), admissão em unidade de terapia intensiva (OR 2,00 CI 1,07-3,74) e dessaturação na admissão (OR 3,72 CI 1,41-9,84) foram mais prováveis de ocorrer entre mulheres negras. A mortalidade materna foi maior entre as negras (7,8% vs. 2,6%, p = 0,048). Os resultados perinatais foram semelhantes entre os dois grupos. Conclusão Mulheres negras brasileiras tiveram maior probabilidade de morrer devido às consequências da COVID-19.

The COVID-19 pandemic in Brazilian pregnant and postpartum women: results from the REBRACO prospective cohort study.

Brazil presented a very high number of maternal deaths and evident delays in healthcare. We aimed at evaluating the characteristics of SARS-CoV-2 infection and associated outcomes in the obstetric population. We conducted a prospective cohort study in 15 Brazilian centers including symptomatic pregnant or postpartum women with suspected COVID-19 from Feb/2020 to Feb/2021. Women were followed from suspected infection until the end of pregnancy. We analyzed maternal characteristics and pregnancy outcomes associated with confirmed COVID-19 infection and SARS, determining unadjusted risk ratios. In total, 729 symptomatic women with suspected COVID-19 were initially included. Among those investigated for COVID-19, 51.3% (n = 289) were confirmed COVID-19 and 48% (n = 270) were negative. Initially (before May 15th), only 52.9% of the suspected cases were tested and it was the period with the highest proportion of ICU admission and maternal deaths. Non-white ethnicity (RR 1.78 [1.04-3.04]), primary schooling or less (RR 2.16 [1.21-3.87]), being overweight (RR 4.34 [1.04-19.01]) or obese (RR 6.55 [1.57-27.37]), having public prenatal care (RR 2.16 [1.01-4.68]), planned pregnancies (RR 2.09 [1.15-3.78]), onset of infection in postpartum period (RR 6.00 [1.37-26.26]), chronic hypertension (RR 2.15 [1.37-4.10]), pre-existing diabetes (RR 3.20 [1.37-7.46]), asthma (RR 2.22 [1.14-4.34]), and anaemia (RR 3.15 [1.14-8.71]) were associated with higher risk for SARS. The availability of tests and maternal outcomes varied throughout the pandemic period of the study; the beginning was the most challenging period, with worse outcomes. Socially vulnerable, postpartum and previously ill women were more likely to present SARS related to COVID-19.

Preeclampsia among women with COVID-19 during pregnancy and its impact on maternal and perinatal outcomes: Results from a national multicenter study on COVID in Brazil, the REBRACO initiative.

OBJECTIVE: To evaluate the prevalence of preeclampsia among cases of COVID-19 infection during pregnancy and the association between both conditions, in a multicenter cohort of Brazilian women with respiratory symptoms. STUDY DESIGN: Ancillary analysis of the Brazilian Network of COVID-19 in Obstetrics (REBRACO) study. We performed a nested case-control analysis selecting all women with COVID-19 and compared outcomes between women with and without PE. MAIN OUTCOMES: Maternal, gestational, and clinical characteristics and perinatal outcomes. MEASURES: Prevalence ratio (PR) and its 95%CI for each of the predictors and outcomes. RESULTS: A total of 203 women were included: 21 (10.3%) in PE group and 182 (89.7%) in non-PE group. Preeclampsia was not different among women with and without COVID-19 (10.3% vs 13.1%, p-value = 0.41), neither complication such as eclampsia and HELLP syndrome. Chronic hypertension (33.4%) (p < 0.01) and obesity (60.0%) (p = 0.03) were the most frequent comorbidities in PE group, and they were significantly more frequent in this group. Women with PE had more cesarean section (RR 5.54 [1.33 - 23.14]) and their neonates were more frequently admitted to neonatal intensive care unit (PR 2.46[1.06 - 5.69]), most likely due to preterm-birth-related complications. CONCLUSION: The prevalence of PE among women with COVID-19 infection during pregnancy was around 10%; women with COVID-19 and a history of chronic hypertension or obesity are more likely to have preeclampsia. Cesarean section is increased among women with PE and COVID-19, with increased rates of neonatal admission to intensive care units, mostly due to prematurity.

Brazilian network of COVID-19 during pregnancy (REBRACO: a multicentre study protocol).

INTRODUCTION: The aim of this study was to evaluate the clinical, epidemiological and laboratory aspects of SARS-CoV-2 infection during pregnancy and postpartum in 16 maternity hospitals. METHODS AND ANALYSIS: A prospective multicentre study, with five axes. First, the prevalence of SARS-CoV-2 infection among women admitted for childbirth will be described in a cross-sectional study. Second, maternal and perinatal outcomes will be assessed in a prospective cohort study including pregnant or postpartum women with suspected COVID-19. Third, a cohort of positive COVID-19 cases with sampling of a variety of biological material. Histopathological and viral analysis of biological maternal and neonatal samples will be performed, and the assessment of nutritional variables to evaluate the association between vitamin D and severity of infection. Fourth, a monitoring and evaluation committee to collect relevant healthcare information and plan actions in centres facing the pandemic. Furthermore, qualitative studies will be performed to study pregnant women, their families and health professionals. Fifth, an ecological study will monitor the number of live births, stillbirths and other outcomes to explore any trend among the periods before, during and after the pandemic. Data will systematically be collected in an electronic platform following standardised operational procedures. For quantitative study components, an appropriate statistical approach will be used for each analysis. For qualitative data, in-depth interviews recorded in audio will be transcribed, checking the text obtained with the recording. Subsequently, thematic analysis with the aid of the NVivo programme will be performed. ETHICS AND DISSEMINATION: Ethical approval was obtained (letters of approval numbers 4.047.168, 4.179.679 and 4.083.988). All women will be fully informed to sign the consent form before enrolment in the study. Findings will be disseminated through peer-reviewed journals and scientific conferences.

Facing the COVID-19 pandemic inside maternities in Brazil: A mixed-method study within the REBRACO initiative.

INTRODUCTION: COVID-19 pandemic posed major challenges in obstetric health care services. Preparedness, development, and implementation of new protocols were part of the needed response. This study aims to describe the strategies implemented and the perspectives of health managers on the challenges to face the pandemic in 16 different maternity hospitals that comprise a multicenter study in Brazil, called REBRACO (Brazilian network of COVID-19 during pregnancy). METHODS: Mixed-method study, with quantitative and qualitative approaches. Quantitative data on the infrastructure of the units, maternal and perinatal health indicators, modifications on staff and human resources, from January to July/2020. Also, information on total number of cases, and availability for COVID-19 testing. A qualitative study by purposeful and saturation sampling was undertaken with healthcare managers, to understand perspectives on local challenges in facing the pandemic. RESULTS: Most maternities early implemented their contingency plan. REBRACO centers reported 338 confirmed COVID-19 cases among pregnant and post-partum women up to July 2020. There were 29 maternal deaths and 15 (51.8%) attributed to COVID-19. All maternities performed relocation of beds designated to labor ward, most (75%) acquired mechanical ventilators, only the minority (25%) installed new negative air pressure rooms. Considering human resources, around 40% hired extra health professionals and increased weekly workload and the majority (68.7%) also suspended annual leaves. Only one center implemented universal screening for childbirth and 6 (37.5%) implemented COVID-19 testing for all suspected cases, while around 60% of the centers only tested moderate/severe cases with hospital admission. Qualitative results showed that main challenges experienced were related to the fear of the virus, concerns about reliability of evidence and lack of resources, with a clear need for mental health support among health professionals. CONCLUSION: Study findings suggest that maternities of the REBRACO initiative underwent major changes in facing the pandemic, with limitations on testing, difficulties in infrastructure and human resources. Leadership, continuous training, implementation of evidence-based protocols and collaborative initiatives are key to transpose the fear of the virus and ascertain adequate healthcare inside maternities, especially in low and middle-income settings. Policy makers need to address the specificities in considering reproductive health and childbirth during the COVID-19 pandemic and prioritize research and timely testing availability.

Combate à mortalidade materna no âmbito hospitalar / Combating maternal mortality in hospital

No início do século XXI mortalidade materna já era uma séria preocupação entre os especialistas em saúde pública e ainda hoje suas altas taxas representam um desafio à humanidade . A sub-priorização de serviços que apenas as mulheres necessitam e a falta de mecanismos de responsabilização para responder às mortes maternas representam o cerne dos demais fatores que contribuem para o grande número de óbitos evitáveis no mundo. Os comitês de mortalidade materna, por avaliarem a causa raiz e criar estratégias de combate ao óbito representam um importante instrumento para a redução da mortalidade materna. Os primeiros comitês conhecidos foram criados na Filadélfia, em 1931, e em Nova Iorque, no ano seguinte. Mas a experiência internacional mais conhecida acabou sendo a do Reino Unido. Preocupados em diminuir o número de mortes maternas, os ingleses iniciaram em 1952 a primeira Investigação Confidencial sobre Mortes Maternas. Os resultados serviram como base para o desenvolvimento de medidas capazes de prevenir os óbitos. E foi tão positivo que as investigações continuam se realizando até hoje, com publicação periódica de relatórios. No Brasil, a Política de Assistência Integral à Saúde da Mulher (PAISM), delineada em 1984 pelo Ministério da Saúde, vem implantando os comitês estaduais de morte materna, mas foi a partir de 1987 que, de fato, se deu o desenvolvimento dos comitês de morte materna em todo o Brasil. Em 2005, estavam implantados os 27 comitês estaduais, 172 comitês regionais, 748 municipais e 206 hospitalares. Apesar de constituir estratégia bem aceita por todos os estados brasileiros, a implantação de comitês oscila entre avanços e retrocessos. Isso indica a necessidade de se fortalecer o controle social neste processo, de forma a garantir a sua continuidade.

At the beginning of the twenty-first century, maternal mortality was already a serious concern among public health experts, and even today its high rates pose a challenge to humanity. The sub-prioritization of services that only women need and the lack of accountability mechanisms to respond to maternal deaths represent the core of the other factors that contribute to the large number of preventable deaths worldwide. Maternal mortality committees, by assessing the root cause and devising strategies to combat death, are an important tool for reducing maternal mortality. The first known committees were created in Philadelphia in 1931 and in New York the following year. But the best-known international experience ended up being that of the United Kingdom. Concerned to reduce the number of maternal deaths, the British initiated the first Confidential Investigation on Maternal Deaths in 1952. The results served as a basis for the development of measures capable of preventing deaths. And it was so positive that the investigations continue to be carried out until now, with periodical publication of reports. In Brazil, the Policy for Comprehensive Assistance to Women's Health (PAISM), outlined in 1984 by the Ministry of Health, has been implementing state committees for maternal deaths, but since 1987, in fact, the development of committees of maternal death in Brazil. In 2005, the 27 state committees, 172 regional committees, 748 municipal committees and 206 hospitals were in place. Although it is a strategy well accepted by all Brazilian states, the implementation of committees oscillates between advances and setbacks. This indicates the need to strengthen social control in this process, in order to ensure its continuity.

En el inicio del siglo XXI la mortalidad materna ya era una seria preocupación entre los especialistas en salud pública y aún hoy sus altas tasas representan un desafío a la humanidad. La sub-priorización de servicios que sólo las mujeres necesitan y la falta de mecanismos de responsabilización para responder a las muertes maternas representan el núcleo de los demás factores que contribuyen al gran número de muertes evitables en el mundo. Los comités de mortalidad materna, por evaluar la causa raíz y crear estrategias de combate al óbito, representan un importante instrumento para la reducción de la mortalidad materna. Los primeros comités conocidos fueron creados en Filadelfia, en 1931, y en Nueva York, al año siguiente. Pero la experiencia internacional más conocida acabó siendo la del Reino Unido. Preocupados en disminuir el número de muertes maternas, los ingleses iniciaron en 1952 la primera Investigación Confidencial sobre Mortes Maternas. Los resultados sirvieron como base para el desarrollo de medidas capaces de prevenir las muertes. Y fue tan positivo que las investigaciones continúan realizándose hasta hoy, con publicación periódica de informes. En Brasil, la Política de Asistencia Integral a la Salud de la Mujer (PAISM), delineada en 1984 por el Ministerio de Salud, viene implantando los comités estaduales de muerte materna, pero fue a partir de 1987 que, de hecho, se dio el desarrollo de los comités de muerte materna en todo Brasil. En 2005, se implantaron los 27 comités estaduales, 172 comités regionales, 748 municipales y 206 hospitales. A pesar de constituir una estrategia bien aceptada por todos los estados brasileños, la implantación de comités oscila entre avances y retrocesos. Esto indica la necesidad de fortalecer el control social en este proceso, para garantizar su continuidad.