UCLA

Persons infected with SARS-CoV-2 during pregnancy are at increased risk of severe COVID-19, including hospitalization, mechanical ventilation, and death. The effects of the pandemic on maternal mortality and morbidity in Brazil, a country disproportionately impacted by COVID-19, have not been well-characterized. We set out to quantify the effect of the COVID-19 pandemic on maternal mortality in Brazil, as well as identify individual, municipal, and state factors that impacted COVID-19-related maternal mortality and morbidity during the pandemic. Using publicly-available databases through the Brazilian Ministry of Health, we estimated 4,995 maternal deaths from January 1, 2020 to December 31, 2021. Using two complementary forecast models, we demonstrated that the observed maternal mortality ratio (MMR) in 2021 was more than double the predicted MMR based on historical maternal mortality data. From January 1, 2021 to December 31, 2021, there were 10,435 pregnant or postpartum persons hospitalized with COVID-19 in Brazil, of which 1,059 (10.1%) resulted in death. Using a random effects model, a single dose of an approved COVID-19 vaccine prior to hospitalization reduced the odds of maternal death by 66%, and estimated state vaccine coverage >90% reduced the odds of maternal death by 89%. Among this hospitalized population, 3,055 individuals required an intensive care unit (ICU) admission. Using nested logistic regression models (LRMs) and multilevel models (MLMs) to incorporate both individual-level and municipal-level factors, we found that COVID-19 vaccination reduced the odds of maternal ICU admission by 38%. Municipal-level health factors, including high family health strategy coverage and ICU bed rates, were not significantly associated with protection against ICU admission when controlling for clustering in the LRM, or in the MLM with inclusion of municipal-level factors. The national COVID-19 vaccination campaign, including targeting pregnant and postpartum individuals, should remain a cornerstone of the Brazilian public health armamentarium in efforts to reduce the national MMR, and protect against maternal death and ICU admissions due to COVID-19.