Maternal and perinatal outcomes associated with COVID-19 among pregnant and postpartum women in public and private hospitals in Brazil

doi:10.21203/rs.3.rs-2129685/v1

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Maternal and perinatal outcomes associated with COVID-19 among pregnant and postpartum women in public and private hospitals in Brazil

https://doi.org/10.21203/rs.3.rs-2129685/v1

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Introduction

Brazil is a country of continental dimensions with a great challenge to ascertain adequate healthcare throughout regions. The country registered increased numbers of maternal deaths and adverse perinatal outcomes in pregnant and postpartum women with COVID-19 infection, rising great concern. There is scarce data on findings among public versus private settings.

Objective

to compare maternal and perinatal outcomes in pregnant and postpartum women with SARS-CoV-2 infection, among admissions in public and private maternity hospitals during a period before vaccination.

Study Design

Secondary analysis of the REBRACO initiative, a national multicenter cohort study in Brazil, considering pregnant and postpartum women with suspected or confirmed COVID-19 infections (from February 2020 to February 2021) in 15 maternity centers (2 private and 13 public facilities). Sociodemographic and obstetric characteristics were compared according to the type of hospital care. In addition, clinical, laboratory findings and maternal and perinatal outcomes were compared in both groups. The prevalence ratio (PR) and its 95%CI for each predictor and outcome were calculated.

Results

Of 559 symptomatic cases tested, 289 confirmed COVID-19 cases were included, with 213 (72.7%) women in public hospitals and 76 (27.3%) women in private hospitals. SARS-CoV-2 infection frequency was not significantly different among groups. Women treated at public hospitals had lower schooling (p < 0.001), and half of them declared that their pregnancy was not planned. There were 13 maternal deaths among women treated at public services and no maternal deaths among pregnant women treated at private hospitals (p-value – 0,024). Pregnant women in public hospitals had higher rates of fever (p-value – 0,041), tachypnea (p-value – 0,003), abnormal laboratory findings in liver enzymes (p-value – 0,005), severe acute respiratory syndrome SARS (p-value 0.014) and their neonates presented more neonatal respiratory distress (p-value – 0,020).

Conclusion

Adverse maternal and perinatal outcomes were worse in the public hospital group with increased rates of severe acute respiratory syndrome and neonatal respiratory distress. The alarming difference between the number of deaths in patients treated in the public and private sector calls attention to the need to better understand the differences in access to health and other delays experienced by patients of different social levels.

COVID-19

SARS-CoV-2

pandemic

pregnancy complications

maternal health

delivery of Health Care

COVID-19 infection can be asymptomatic in up to 75% of pregnant women. When symptomatic the infection can be classified according to the severity of the symptoms in mild, moderate, and severe. Most symptomatic cases during gestation present a mild infection (85%). Approximately 15% progress to severe forms and 4% of pregnant women infected may require admission to the intensive care unit and 3% invasive ventilation. [1]

Understanding the impact of structural and social changes due to the pandemic on perinatal outcomes was identified as a research priority.[2]

Since the beginning of the pandemic, in Brazil, the lethality of the disease in severe cases of pregnant and postpartum women by COVID-19 has been higher than that registered by developed countries.[3] As an example of substandard care, according to previous studies, one in five deaths of pregnant and postpartum women due to COVID-19 did not have access to intensive care units (ICU). [4]

The health system in Brazil is divided into three subsectors: the public subsector (SUS), in which services are financed and provided by the State; the private subsector, in which private resources finance services; and, finally, the supplementary health subsector, with different types of private health insurance plans and policies, and supported by tax subsidies.[5] Brazil, is a country of continental dimensions in addition to being a country with great inequality of income and education, also with great inequalities in the provision and quality of health care services. The impact of COVID-19 is markedly different in different countries around the world, and the reasons for this diversity are certainly multifactorial, including socioeconomic and geographic influences.[6] The lack of public health models that resemble the Brazilian health model leads to difficulties in making comparisons between the quality and capacity of adequate care for the infection caused by SARsCOV-2 in pregnant women throughout the different scenarios of the pandemic.

To know the different Brazilian realities can help to understand this disease and prevent maternal and perinatal morbidity and mortality. This study aimed to compare the characteristics and outcomes of pregnant and postpartum women admitted due to COVID-19 infection, in the public or private sector in different maternity centers in Brazil.

This study was a secondary analysis of the Brazilian REBRACO Network, a national multicenter study that aimed to understand the impact of COVID-19 during pregnancy in a Brazilian obstetric population. Pregnant women with a suspected and/or confirmed infection by COVID-19 were followed and maternal and perinatal data were collected in public and private hospitals comprising 15 maternity centres around the country. Data for both outpatient and hospitalized women were collected from 01 February 2020 to 28 February 2021, before the implementation of vaccination against COVID-19 infection.

Eligibility criteria included pregnant women who attended obstetrical services of the participating centers presenting flu-like symptoms and confirmed COVID-19 infection.

Flu-like symptoms considered were fever, cough, shortness of breath, sputum production, nasal or conjunctival congestion, difficulty swallowing, sore throat, runny nose, and clinical signs of respiratory distress or effort, such as O2 saturation < 95%, signs of cyanosis, flapping of the nose, intercostal retraction, dyspnea, diarrhea, anosmia, and dysgeusia.

The COVID-19 diagnosis was confirmed by laboratory and/or radiologic pulmonary findings. Other symptomatic COVID-19 infection criteria included coughing, fever, nausea, vomiting, tachypnea, dyspnea, and chest pain. Participants (presenting with at least one of the aforementioned symptoms) were tested for SARS-CoV-2 infection according to local availability of testing and were submitted to laboratory exams and/or CT scans following local clinical protocols.

Women who had a negative test (RT-PCR or rapid test), women who were not tested, and did not have ground-glass opacities compatible abnormalities in CT-scan if submitted to the radiological investigation were considered negative for COVID-19 infection and were not considered eligible for the study.

For the evaluation of pregnancy outcomes, only women who tested positive for COVID-19 and whose follow-up was considered successful (childbirth information and COVID-19 status available) were included in the analysis. Women with late pregnancy outcomes unavailable (unknown mode of delivery and gestational age at delivery), postpartum women at enrolment, and women with an ongoing pregnancy at the time of this analysis were not considered.

We collected information on sociodemographic, pregnancy, and medical history characteristics and on the initial clinical presentation of COVID-19. After the clinical presentation of a case of COVID-19, the women were followed until childbirth and postpartum.

The women were split into two groups, including 15 maternity hospitals from 4 Brazilian regions. The groups were divided into the following centers: Public Hospitals group: Women’s Hospital of the University of Campinas, Sao Paulo (SP); Hospital of Jundiai School of Medicine (SP); Clinics Hospital of Porto Alegre, Rio Grande do Sul (RS); Minas Gerais (MG); Maternity Hospital of Federal University of Ceara (CE); Hospital of Federal University of Sao Paulo (SP); Jorge Rossmann Regional Hospital of Itanhaem (SP); Hospital of Federal University of Sao Carlos (SP); Sumare State Hospital (SP); Hospital of Federal University of Minas Gerais (MG); Fernandes Figueira Institute, Rio de Janeiro (RJ); Hospital of the Sao Paulo State University in Botucatu (SP); Hospital of Federal University of Pernambuco (PE); and Santa Casa de Misericordia of Para (PA) and Private Hospitals group: UNIMED Maternity of Belo Horizonte (MG) and Moinhos de Vento Hospital of Porto Alegre (RS).

Study data were collected and managed using REDCap®15 (Research Electronic Data Capture) tools hosted at CAISM/Unicamp server, the coordinating center. Research collaborators had hierarchical and clustered access to the system; data was properly anonymized, and personal contact information was kept confidential.

Statistical Analysis And Data Management

We reported the number of women with positive COVID-19 infection, the proportion of cases investigated (tests for COVID-19 performed), and cases confirmed for all participants in the considered period.

We compared sociodemographic (age, education, marital status, pre-gestational body mass index - BMI, region), pregnancy conditions (multiple pregnancies, parity, planned or unplanned pregnancy, type of prenatal insurance), and medical condition characteristics (alcohol use, asthma, chronic kidney disease, diabetes, hypertension, and smoking) between women who attended public and private hospitals for childbirth. For descriptive purposes, the North and Northeast Brazilian regions were grouped. To assess obstetric outcomes, the following variables were evaluated: mode of birth, miscarriage, fetal death, prematurity (any childbirth < 37 weeks), pre-eclampsia (new onset of hypertension, blood pressure higher or equal to 140x90mmHg in two or more measures, after 20 weeks of gestation with proteinuria or other laboratory or clinical signs of organ dysfunction), birth weight (adequacy of birth weight according to gestational age according to the GROW customized chart), Apgar score (below 7 at 5 minutes), respiratory distress, admission to NICU (neonatal intensive care unit), and neonatal death.

The information regarding the severity of COVID-19 infection included severe acute respiratory syndrome (SARS), admission to the NICU, need for intubation and prone position, renal impairment, maternal death, and any severe maternal outcomes. Severe maternal outcomes (SMO) were defined as having any of the following: SARS, admission to ICU, or maternal death.

Women were grouped into two groups of reference hospitals, predominantly public care and private health service participating in the REBRACO network. Data were subsequently dichotomized into Public and Private groups. For comparisons using qualitative variables, Chi-squared or Fisher's Exact tests were used when appropriate to assess statistical significance between groups according to the number of subjects. For the analysis of quantitative variables, the Pearson and Spearman correlations were used according to the distribution of normality. To determine the association of COVID-19 infection with pregnancy outcomes in public and private hospitals, we estimated unadjusted risk ratios with their 95% confidence intervals.

We used SPSS 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp) for statistical analysis.

The study protocol followed the Declaration of Helsinki amended in 1964 and it was approved by the Institutional Review Board (IRB) of the coordinating center and by each participating center (Approval number 31591720.5.3005.5330). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed for the implementation and reporting of the study. All included women received detailed information about the study and provided informed consent to their participation prior to being enrolled.

From the initial 729 symptomatic pregnant women included in the database of the study, this analysis considered all confirmed positive cases with data on pregnancy outcomes, including a total of 289 cases, with 213 women from public hospitals and 76 women from private hospitals. Figure 1 shows the flowchart of included cases, with details on exclusion criteria.

Sociodemographic and obstetric data are shown in Table 1. There was a higher proportion of low education level (None/Primary incomplete) among women cared for in the Public Health System Women (11.4% vs. 0%). Group of Public Hospitals had a higher rate of unplanned pregnancy (50% vs. 28.9%). In private hospital group, first pregnancy represented a greater proportion of public insurance used for prenatal care (80∙3% vs. 72∙2%) and had a smaller BMI (40∙9% vs. 25.7%) more often with a partner (61.8% vs. 76.3%). It was the first pregnancy of 31.8% of women treated in public hospitals, while 46.1% of women were primigravidae in private hospitals.

There was no significant difference between women admitted at the public or private centers regarding the maternal age < 19 years (6.6% vs 1.3%) and skin colour non-white (45.5% vs 40.8%). Looking into previous clinical and obstetric conditions comorbidities (chronic hypertension, gestational diabetes, and asthma) were not significantly different among groups.

The majority of women in both groups were evaluated in the hospital, due to COVID-19 symptoms, reporting < 7 days of such symptoms, as shown in Table 2. It also shows that clinical manifestations of COVID-19-related symptoms were similar in women, however fever, tachypnea, and any glutamic oxaloacetic transaminase (SGOP) ≥ 70 were higher levels in women admitted to public hospitals group (44,6% vs 30,3%, 32,2% vs 11,5% and 11% vs 50,0% respectively), they differ significantly.

There was no difference between the two groups in terms of prematurity, the occurrence of pre-eclampsia, mode of birth, birth weight, low Apgar score, or admission to the ICU.

Considering maternal outcomes, Table 3 shows that women from private hospitals had a higher risk of severe acute respiratory syndrome (SARS) (19,7% vs 6,7%) p-value 0,014. Occurrence of admission to ICU had a higher frequency among women in the group of patients from public hospitals (16,5% vs 8,0%), and the same occurred to neonatal respiratory distress and neonatal death, although those differences were not significant, possibly due to the low numbers.There were 13 maternal deaths among women treated at public services and no maternal deaths among pregnant women treated at private hospitals.

Table 1

Sociodemographic, previous clinical and obstetric conditions characteristics of symptomatic women with confirmed COVID-19, according to the type of hospital care
Women's characteristics	Public Hospitals (n = 213)	Private Hospitals (n = 76)	p
	n (%)	n (%)
Maternal age			0.105
≤ 19	14 (6.6)	1 (1.3)
20–35	154 (72.3)	53 (69.7)
> 35	45 (21.1)	22 (28.9)
Skin Colour¹			0.483
White	114 (54.5)	45 (59.2)
Non white	95 (45.5)	31 (40.8)
Schooling²			< 0.001
None/Primary incomplete	20 (11.4)	0 (0.0)
Primary/Secondary	118 (67.0)	20 (31.7)
College or higher	38 (21.6)	43 (68.3)
First pregnancy³	67 (31.8)	35 (46.1)	0.026
Multiple pregnancy	9 (4.2)	1 (1.3)	0.464
With partner⁴	128 (61.8)	58 (76.3)	0.023
Health insurance of Antenatal care⁵			< 0.001
Public	186 (94.9)	0 (0.0)
Private	10 (5.1)	74 (100)
Pregnancy status at enrolment			0.368
Pregnant	195 (91.5)	72 (94.7)
Postpartum	18 (8.5)	4 (5.3)
Trimester of Diagnosis of COVID-19			0.079
1 st trimester	23 (10.8)	13 (17.1)
2 nd trimester	48 (22.5)	25 (32.9)
3 rd trimester	124 (58.2)	34 (44.7)
Postpartum	18 (8.5)	4 (5.3)
Chronic Hypertension	18 (8.5)	7 (9.2)	0.840
Obesity	54 (40.9)	18 (25.7)	0.046
Gestational Diabetes	5 (2.3)	1 (1.3)	0.588
Asthma	18 (8.5)	3 (3.9)	0.194
Region			< 0.001
North/Northeast	45 (21.1)	0 (0.0)
Southeast	143 (67.1)	42 (55.3)
South	25 (11.7)	34 (44.7)
Unplanned pregnancy⁶	87 (50.0)	22 (28.9)	0.002
Missing information for: ¹ 4, ²50, ³2, ⁴6, ⁵19, ⁶39

Table 2

Clinical and laboratory manifestations at the inclusion of symptomatic women with confirmed COVID-19-19-19-19, according to the type of hospital care
Clinical and laboratory manifestations	Public Hospitals	Private Hospitals	P
Time since the onset of symptoms (days)¹			0.018
< 7 days	153 (76.1)	43 (60.6)
≥ 7 days	48 (23.9)	28 (39.4)
Fever > 38oC	95 (44.6)	23 (30.3)	0.041
Cough	137 (64.3)	45 (59.2)	0.513
Nasal congestion	37 (17.4)	28 (36.8)	0.001
Coryza	74 (34.7)	35 (46.1)	0.108
Dyspnea	86 (40.4)	23 (30.3)	0.155
Saturation of O2 < 95%²	20 (9.6)	2 (3.3)	0.180
Chest pain	13 (6.1)	5 (6.6)	1.000
Tachypnea³	64 (32.2)	7 (11.5)	0.003
Any SGOP ≥ 70⁴**	12 (11.0)	5 (50.0)	0.005
SGTP ≥ 70 (Admission)⁵	4 (3.9)	2 (22.2)	0.073
Any SGTP ≥ 70⁶	7 (6.6)	4 (40.0)	0.007
Platelets count < 100,000⁷	12 (10.2)	0 (0.0)	0.359
Creatinine ≥ 1.2mg/dL⁸	15 (13.0)	2 (14.3)	1.000
* SGOP: glutamic oxaloacetic transaminase; ** SGTP: glutamic pyruvic transaminase; ICU: intensive care unit. Missing information for: ¹17, ²20, ³29, ⁴170, ⁵177, ⁶173, ⁷156, ⁸160

Table 3

Pregnancy outcomes of symptomatic women with confirmed COVID-19, according to the type of hospital care
Pregnancy outcomes		Public Hospitals		Private Hospitals		p
Severe Maternal Outcome*
Maternal death		13 (6,4)		0 (0,0)		0,024
Admission to ICU**	30 (16,5)		4 (8,0)		0,202
Any SRAG***	42 (19,7)		5 (6,7)		0,014
Fetal Death¹	4 (2,6)		0 (0,0)		0,577
Preterm Birth²	49 (32,5)		10 (22,7)		0,294
Low Birthweight³	36 (27,7)		6 (15,8)		0,201
Apgar 5ºmin < 7⁴	9 (6,1)		0 (0,0)		0,213
Neonatal Respiratory Distress⁵	39 (28,1)		4 (9,3)		0,020
Admission to Neonatal ICU⁶	44 (30,8)		7 (15,9)		0,082
Neonatal Morbidity⁷	19 (16,2)		3 (7,1)		0,229
Neonatal Death⁸	5 (3,5)		2 (4,8)		0,658
APO WHO⁹	61 (39,9)		12 (27,3)		0,178
SARS, admission to NICU or maternal death, intensive care unit. Severe acute respiratory syndrome **Adverse Perinatal Outcomes according to WHO definition Missing information for: ¹1, ²3, ³30, ⁴8, ⁵16, ⁶11, ⁷39, ⁸13, ⁹1

Our findings reveal differences in the sociodemographic profile and maternal-fetal outcomes of pregnant women with COVID-19 infection treated at public and private hospitals. Pregnant women and puerperal women treated in public hospitals have less schooling, and more often had unplanned pregnancies and no partner. On the other hand, there was no significant difference in the variables age, skin colour, and comorbidities in women treated in different health sectors in Brazil among both groups.

The results obtained analysing the sociodemographic characteristics show that women assisted in the public network have lower levels of education, a greater number of multiparous women, and higher rates of unplanned pregnancies. Similar data from the World Health Organization indicate that, in Brazil, of the total number of births in the last five years, only 54% were planned for that moment. [7]. Currently, the Unified Health System (SUS) offers several contraceptive methods. Among these methods, the copper IUD stands out, which is widely used worldwide (around 15%). In contrast, there is a low record of use in Brazil, with estimated use, according to PNDS data 2006, around 1.9%.[8]

Just as maternal schooling has been presented as an independent variable in epidemiological studies covering a wide range of topics. Mothers with less education have more than three children when compared to mothers with higher education, according to a study carried out in Brazil. [9].

It is relevant to consider that all maternity centers included are referral centers for care in COVID-19 and mostly university hospitals, not representing the overall comparison of public versus private assistance in the country, and therefore, most of the differences were driven by baseline disparities and delays more frequent among the population of low-income settings.

We aimed to compare maternal and perinatal outcomes associated with COVID-19 among pregnant and postpartum women in public and private hospitals in Brazil. Our findings show that in comparison among groups there were 13 maternal death outcomes, SARS and Neonatal Respiratory Distress were worse in public hospitals and there were no maternal deaths among women followed during the study in the private hospital group. Such findings suggest that we have disparities in our population, and illustrate how these marked differences may influence access to health services and the quality of care provided. In Brazil, during the first wave of the pandemic, maternal mortality reached very worrying levels, which is reflected in the maternal outcomes observed during our study.[10]. The centers that were part of the REBRACO study were appointed as regional reference hospitals for the treatment of patients with COVID-19. Despite the increase in the number of ICU beds admissions surpassed operational capacity. with the abrupt increase in the number of cases in the second half of 2020, even with the increase in the number of beds and the reallocation of staff to care for these patients, it was still not enough and patients with acute respiratory failure requiring advanced respiratory support had to be treated outside of hospitals. intensive care units.[11]

Since the publication of Allotey, 2020 data from the United Kingdom, Spain and the USA show that there were more obstetric problems among pregnant women with coronavirus infection-19.[12]. The Delta variant causes more severe COVID-19. The 2nd wave that started in June and July 2020 in the US showed a trend towards an increase in cases of severe COVID-19. UK MBRRACE data show an increase in adverse outcomes in pregnant women with COVID-19. MBRRACE reports also show that of 10 women who died in the UK, 8 were black and from ethnic minorities (Draper ES,021). In 7 cases the deaths were related to COVID-19. More recent data also reports that 60% of deaths from direct COVID-19 were black and ethnic minorities in the UK. Only 1 pregnant woman out of 10 women received the support recommended by the current guidelines for the treatment of COVID-19.

Recent publications have attempted to understand how existing structures of socioeconomic inequality, as well as pandemic-related social and economic stressors, influence SARS-CoV-2 infection during pregnancy and adverse birth outcomes.[13] In this New York City study, structural racism and community unemployment were associated with SARS-CoV-2 infection and preterm birth. In Brazil, socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the pandemic, with disproportionately adverse in states and municipalities with greater vulnerability socioeconomic.[14] Although COVID-19 was first recorded in São Paulo and Rio de Janeiro, in the Southeast region, death rates increased quickly in states with marked socioeconomic vulnerabilities, particularly in the North and Northeast regions. Although states with greater vulnerability had higher mortality rates during the initial spread of COVID-19 in Brazil, these regions, due to their greater coverage of social assistance and stronger primary care, we're able to implement public policies to expand hospital capacity and regulations to try to increase physical distancing, positively, even so, it was not enough to reduce the increased mortality rates from COVID-19 in these regions. [14]

We did not observe statistically significant differences in ethnicity between the two groups in our study, In Brazil, the concept of ethnicity is particularly complex due to great miscegenation, and the term “Pardo” thus represents a diverse range of ethnic-mixed backgrounds. Nevertheless, another Brazilian study (including 669 maternal SARS-CoV-2 cases) reported that black women were more likely to be admitted with low O2 saturation at admission. [15].This suggests possible difficulties in gaining access to health services as these participants took longer to get to the hospital.

We have evidence that disease severity is positively correlated with gestational age at the time of infection. [16] A large study in a geographically diverse U.S. cohort demonstrated that the frequency of adverse pregnancy-related outcomes did not differ between those classified as positive compared with negative for SARS-CoV-2 infection during pregnancy. Women with evidence of testing were more likely to live in ZIP codes in the top 25th percentile Social Vulnerability Index (the most vulnerable population) compared with those without evidence of testing. Women positive for SARS-CoV-2 infection were more likely to be Hispanic, more likely to have public insurance, more likely to be socially vulnerable, and more likely to be obese compared with those considered negative for SARS-CoV-2 infection.[17]. It is noteworthy that postal codes with greater socioeconomic vulnerability had higher numbers of tests, probably due to prioritization or because these Hospitals are better equipped to carry out these tests.

Our first question is whether there are differences in maternal and perinatal outcomes of pregnant women with COVID-19 infection followed by the REBRACO network managed in public or private hospitals in different regions of Brazil. In our study, about half of the pregnant women listed as symptomatic were not tested for Covid-19 in the public network, while tests were carried out for more than 2/3 of the patients in the private network who had symptoms suspected of being infected by Covid-19.

As suggested in our study, other countries seem to have presented similar numbers, as reported in a 2022 Lancet study, 64.8% (219/338) of pregnant and postpartum women who died from Covid-19 infection were admitted to critical care and 50,2% (160/319) received cardiopulmonary resuscitation. There are two hypothetical pathways by which maternal mortality levels might change: either due to the aggravation of SARS-CoV-2 infection due to the pregnant state or due to interruptions in access to maternity services. [18]. The lack of critical care might reflect barriers to access to intensive care faced by pregnant women, for example, the limited number of beds or the administrative referral process. Low admission rates may also be related to overwhelmed healthcare systems and the lack of critical care beds in these countries.

In 2020, Brazil had a maternal mortality ratio of 74.7 deaths maternal deaths per 100,000 births. In the previous year, in 2019, the maternal death ratio was 55.3. The highest incidence of mortality was observed among black women, over 30 years old, multiparous.17% (n = 335) of all maternal deaths in Brazil in 2020 were associated with Covid-19. [19] Nearly all maternal deaths are preventable and even getting back to pre-pandemic levels of maternal mortality, which were already high, could take more than a decade. According to the Pan American Health Organization (PAHO), “the lack of access to timely care and interruptions in prenatal services are responsible for the increase in maternal mortality in the Americas during the pandemic, with one in three pregnant women unable to access care timely intensives. the challenges and inequities that we faced prior to COVID have worsened and can’t be overlooked”[20].

Some of the limitations of our study are such as that our database does not allow us to determine whether the outcomes are only correlated with the type of care or are there other associated variables. Another limitation is that some Brazilian regions were not included in the study. In addition, this study had a limited sample size.

The changes that are taking place in health systems can last long beyond the COVID-19 pandemic, these effects can delay diagnoses and change maternal-fetal outcomes. Women who suffer domestic violence, belonging to minorities and in less favoured situations, with less access to the internet and remote care, may be less favoured by these changes.

The hybrid health care delivery system increases inequities in access and discrepancies in maternal and neonatal outcomes in pregnant and postpartum women with suspected COVID-19 infections. Brazil has different levels of access to health and with great social inequalities.

The association between worse maternal and perinatal outcomes in vulnerable populations is clear. In countries with different levels of access to health and with great social inequalities, vaccination is a unique opportunity to have equity concerning infection by COVID-19. Therefore, pregnant women should have priority for vaccination against COVID-19.

There were a significant number of maternal deaths among women treated at public services and no maternal deaths among pregnant women treated at private hospitals. Our study also revealed a higher risk of SARS and neonatal respiratory distress in women admitted to public hospitals group. In this context, health care becomes the focus, and access to the health system is an important component in this analysis, with a great impact on mortality rates.

The COVID-19 pandemic has direct and indirect effects on the health of pregnant women and on perinatal outcomes. More studies are needed to differentiate these effects.

Ethics approval and consent to participate

The study protocol followed the Declaration of Helsinki amended in 1964 and it was approved by the Institutional Review Board (IRB) by the Brazilian National Ethics Committee and by Research Ethics Committee at Moinhos de Vento Hospital (Approval number 31591720.5.3005.5330) then each by Research Ethics Committee also received their local approval. The All included women received detailed information about the study and provided informed consent to their participation prior to being enrolled.

Consent for publication

Not applicable

Availability of data and materials

The data are available upon request for Maria Laura Costa, to 101 Alexander Fleming St; Campinas, SP, Brazil or e-mail for [email protected].

Competing interests

The authors declare that they have no conflicts of interest

Funding

The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript. The funding source was FAEPEX-Unicamp under grant number 2300/20.

Authors' contributions

The idea for conceptualising this analyse arose from a discussion among EMA, EVCF, JV, MLC, RTS and JGC. They initially got the contribution of other members of the coordinating centre including the staff, RCP. Then the idea of increasing the initiative to a network for a multicentre study arose and RPT, KGF, SMC, FJAP, FEF, RM, ET, EVCF, JV, SMH, CBA, MDCJ, MABD, LGO, EFMJ, CASM and MGQL were invited and contributed with information for building the proposal. All of them read and agreed on the final form of the manuscript.

Acknowledgements

We would like to thank.the remaining members of the REBRACO Study Group

Sérgio HA Martins-Costa¹, José Geraldo L Ramos¹, Maria Lúcia R Oppermann¹, Laisa S Quadro¹, Lina Marins¹, Érika V Paniz¹, Thaís Vicentini Xavier¹, for the Clinics Hospital of Porto Alegre, Porto Alegre/RS, Brazil; Edson V Cunha Filho², Janete Vettorazzi^1,2, Ellen Machado², Anne Bergmann², Gustavo Raupp dos Santos², Moinhos de Vento Hospital - HMV, Porto Alegre/RS, Brazil; Renato T Souza³, Maria Laura Costa³, Jose G Cecatti³, Rodolfo C Pacagnella³, Carolina C Ribeiro-do-Valle³, Adriana G Luz³, Giuliane J Lajos³, Guilherme M Nobrega³, Thayna B Griggrio³, Charles M Charles³, Silvana F Bento³, Carla Silveira³, Maria J Miele³, Sherly Metelus³, Lester Castro³, Stephanie Pabon³, Amanda D Silva³, Paulo S R Junior³, Thais G Sardinha³, Rodolfo R Japenga³, Erica R F Urquiza³, Maíra R Machado³, Marcela Maria Simões³, Larissa M Solda³, Juliana Vasconcellos Freitas-Jesus³, Rachel Esteves Soeiro³, for the Department of Obstetrics and Gynecology, University of Campinas, Campinas/SP, Brazil; Ricardo P Tedesco⁴, Karayna G Fernandes⁴, Patrícia B Peres⁴, Cristiane L Arbeli⁴, Rafael M Quevedo⁴, Carolina F Yamashita⁴, Julia D Corradin⁴, Isabella Bergamini⁴, for the Jundiaí School of Medicine - HU/FMJ, Jundiaí/SP, Brazil; Frederico JA Peret⁵, Marina HL Almeida⁵, Bruna FV Moura⁵, Lidiane R França⁵, Hanna Vieira⁵, Rafael B Aquino⁵, Aline C Costa⁵, for the UNIMED Maternity - UNIMED/BH, Belo Horizonte/MG, Brazil; Francisco E Feitosa⁶, Daisy Pinheiro⁶, Denise Cordeiro⁶, Priscila L Miná⁶, Carol Dornellas⁶, for the Federal University of Ceará - MEAC/UFC, Fortaleza/CE, Brazil; Rosiane Mattar⁷, Evelyn Traina⁷, Sue Yazaki-Sun⁷, Priscilla Mota⁷, Arimaza C Soares⁷, for Federal University of São Paulo - UNIFESP/EPM, São Paulo/SP, Brazil; Samira M Haddad⁸, Aline Tosetto⁸, Sabrina Savazoni⁸, for the Jorge Rossmann Regional Hospital - Sócrates Guanaes Institute, Itanhaém/SP, Brazil; Carla B Andreucci⁹, Bruna E Parreira⁹ for the Federal University of São Carlos/UFSCAR, São Carlos/SP, Brazil; José P Guida¹⁰, for the Sumaré State Hospital - HES, Sumaré/SP, Brazil; Mario D Correa Junior¹¹, Caio Leal¹¹, Rayra Amana¹¹, for the Federal University of Minas Gerais - HC/UFMG, Belo Horizonte/MG, Brazil; Marcos AB Dias¹², Marcos Nakamura-Pereira¹², Bruna O Guerra¹², Gabriela Gorga¹², for the Fernandes Figueira Institute - IFF/Fiocruz, Rio de Janeiro/RJ, Brazil; Leandro G Oliveira¹³, Kevin FA Oliveira¹³, Mariana Emi Varicoda Makyama¹³, for the São Paulo State University School of Medicine, Botucatu/SP, Brazil; Elias F Melo Junior¹⁴ Débora F Leite¹⁴, Isabella Monteiro¹⁴, for the Federal University of Pernambuco - HC/UFPE, Recife/PE, Brazil; Marília GQ da Luz¹⁵, Isabela R Pereira¹⁵, Clélia Andrade Salustrino¹⁵, Valéria B Pontes¹⁵, Roberto Allen da Silva Franco¹⁵, João Paolo Bilibio¹⁵, Gislânia P F Brito¹⁵, Hana Paula C Pinto¹⁵, Danielle Leal de Oliveira¹⁵, Andrezza A Guerra¹⁵, Andrea O Moura¹⁵, Natasha Pantoja¹⁵, Fernanda David¹⁵, Alina Silva¹⁵, for the Santa Casa de Misericórdia of Pará, Belém/PA, Brazil.

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No competing interests reported.

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Maternal and perinatal outcomes associated with COVID-19 among pregnant and postpartum women in public and private hospitals in Brazil

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