Tracking Excess of Maternal Deaths Directly and Indirectly Associated With COVID-19 in Brazil: A Nationwide Database Analysis

Abstract

Background The COVID-19 pandemic brought a new challenge to maternal mortality in Brazil. Throughout 2020, Brazil registered 549 maternal deaths, mainly concentrated in second and third-trimester pregnant women. The objective of this study was to verify the excess of maternal deaths that occurred in Brazil caused directly and indirectly by Covid-19 in the year 2020. In addition, we sought to identify clinical social and health care factors associated with these maternal deaths, when they were directly caused by Covid-19. Methods We performed nationwide analyses, based on data from the Mortality Information System (SIM), for general deaths and maternal deaths, and the Influenza Epidemiological Surveillance System (SIVEP-Influenza), for estimates of female and maternal deaths due to COVID-19. The methodological approach adopted two distinct techniques. First, we estimated the excess maternal mortality and the breakdown of the excess between total and COVID-19 deaths. Then, we estimated the odds ratios of occurrence of symptoms, comorbidities, social determination proxies, and hospital care aspects between COVID-19 maternal and childbearing age female deaths. We chose women of childbearing age (15 to 49 years) as a reference because sex and age introduce differentials in the risk of COVID-19 death. Results Most of maternal deaths occurred during pregnancy in all months of 2020 (µ = 59.8%, SD = 14.3%, range 50%-100%). Even considering the excess mortality due to COVID-19 for the childbearing age female population, maternal mortality was more penalized. Clinical variables suggest that the chances of occurrence of symptoms among maternal deaths were like those observed in the deaths of women of childbearing age. On the other hand, the odds of being a black woman, living in a rural area and being hospitalized out of the residence municipality among maternal deaths were 44%, 61%, and 28% higher than control group. Odds of hospitalization, ICU admission, and invasive ventilatory support use among maternal deaths were, respectively, 4.37, 1.73, and 1.64 times as control group. Conclusions Differences between the two groups of deaths are significantly associated with social determination and (in)adequate obstetric care. Year 2021 has been more severe for maternal mortality. We need to increase immunization and monitoring among pregnant women immediately.