Excess maternal mortality in Brazil: Regional inequalities and trajectories during the COVID-19 epidemic

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Abstract

Background

The COVID-19 pandemic has exceeded 6 million known disease-related deaths and there is evidence of an increase in maternal deaths, especially in low- and middle-income countries. We aimed to estimate excess maternal deaths in Brazil and its macroregions as well as their trajectories in the first 15 months of the COVID-19 epidemic.

Methods

This study evaluated maternal deaths from the Mortality Information System of the Ministry of Health, with excess deaths being assessed between March 2020 and May 2021 by quasi-Poisson generalized additive models adjusted for overdispersion. Observed deaths were compared to deaths expected without the pandemic, accompanied by 95% confidence intervals according to region, age group, and trimester of occurrence. Analyses were conducted in R version 3.6.1 and RStudio version 1.2.1335.

Results

There were 3,291 notified maternal deaths during the study period, resulting in a 70% excess of deaths regardless of region, while in the North, Northeast, South and Southeast regions, excess deaths occurred regardless of age group. Excess deaths occurred in the March-May 2021 trimester regardless of region and age group. Excess deaths were observed in the Southeast region for the 25-36-year-old age group regardless of the trimester assessed, and in the North, Central-West and South regions, the only period in which excess deaths were not observed was September-November 2020. Excess deaths regardless of trimester were observed in the 37-49-year-old age group in the North region, and the South region displayed explosive behavior from March-May 2021, with a 375% excess of deaths.

Conclusions

Excess maternal deaths, with geographically heterogenous trajectories and consistently high patterns at the time of the epidemic’s greatest impact, reflect not only the previous effect of socioeconomic inequalities and of limited access to maternal health services, but most of all the precarious management of Brazil’s health crisis.

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Observational Study of Hydroxychloroquine in Hospitalized Patients with Covid-19

Joshua D Geleris, Yifei Sun, Jonathan J. Platt … (2020)

Abstract Background Hydroxychloroquine has been widely administered to patients with Covid-19 without robust evidence supporting its use. Methods We examined the association between hydroxychloroquine use and intubation or death at a large medical center in New York City. Data were obtained regarding consecutive patients hospitalized with Covid-19, excluding those who were intubated, died, or discharged within 24 hours after presentation to the emergency department (study baseline). The primary end point was a composite of intubation or death in a time-to-event analysis. We compared outcomes in patients who received hydroxychloroquine with those in patients who did not, using a multivariable Cox model with inverse probability weighting according to the propensity score. Results Of 1446 consecutive patients, 70 patients were intubated, died, or discharged within 24 hours after presentation and were excluded from the analysis. Of the remaining 1376 patients, during a median follow-up of 22.5 days, 811 (58.9%) received hydroxychloroquine (600 mg twice on day 1, then 400 mg daily for a median of 5 days); 45.8% of the patients were treated within 24 hours after presentation to the emergency department, and 85.9% within 48 hours. Hydroxychloroquine-treated patients were more severely ill at baseline than those who did not receive hydroxychloroquine (median ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen, 223 vs. 360). Overall, 346 patients (25.1%) had a primary end-point event (180 patients were intubated, of whom 66 subsequently died, and 166 died without intubation). In the main analysis, there was no significant association between hydroxychloroquine use and intubation or death (hazard ratio, 1.04, 95% confidence interval, 0.82 to 1.32). Results were similar in multiple sensitivity analyses. Conclusions In this observational study involving patients with Covid-19 who had been admitted to the hospital, hydroxychloroquine administration was not associated with either a greatly lowered or an increased risk of the composite end point of intubation or death. Randomized, controlled trials of hydroxychloroquine in patients with Covid-19 are needed. (Funded by the National Institutes of Health.)

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Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State

Eli Rosenberg, Elizabeth M Dufort, Tomoko Udo … (2020)

Among patients with coronavirus disease 2019 (COVID-19), is there an association between use of hydroxychloroquine, with or without azithromycin, and in-hospital mortality? In a retrospective cohort study of 1438 patients hospitalized in metropolitan New York, compared with treatment with neither drug, the adjusted hazard ratio for in-hospital mortality for treatment with hydroxychloroquine alone was 1.08, for azithromycin alone was 0.56, and for combined hydroxychloroquine and azithromycin was 1.35. None of these hazard ratios were statistically significant. Among patients hospitalized with COVID-19, treatment with hydroxychloroquine, azithromycin, or both was not associated with significantly lower in-hospital mortality. Hydroxychloroquine, with or without azithromycin, has been considered as a possible therapeutic agent for patients with coronavirus disease 2019 (COVID-19). However, there are limited data on efficacy and associated adverse events. To describe the association between use of hydroxychloroquine, with or without azithromycin, and clinical outcomes among hospital inpatients diagnosed with COVID-19. Retrospective multicenter cohort study of patients from a random sample of all admitted patients with laboratory-confirmed COVID-19 in 25 hospitals, representing 88.2% of patients with COVID-19 in the New York metropolitan region. Eligible patients were admitted for at least 24 hours between March 15 and 28, 2020. Medications, preexisting conditions, clinical measures on admission, outcomes, and adverse events were abstracted from medical records. The date of final follow-up was April 24, 2020. Receipt of both hydroxychloroquine and azithromycin, hydroxychloroquine alone, azithromycin alone, or neither. Primary outcome was in-hospital mortality. Secondary outcomes were cardiac arrest and abnormal electrocardiogram findings (arrhythmia or QT prolongation). Among 1438 hospitalized patients with a diagnosis of COVID-19 (858 [59.7%] male, median age, 63 years), those receiving hydroxychloroquine, azithromycin, or both were more likely than those not receiving either drug to have diabetes, respiratory rate >22/min, abnormal chest imaging findings, O 2 saturation lower than 90%, and aspartate aminotransferase greater than 40 U/L. Overall in-hospital mortality was 20.3% (95% CI, 18.2%-22.4%). The probability of death for patients receiving hydroxychloroquine + azithromycin was 189/735 (25.7% [95% CI, 22.3%-28.9%]), hydroxychloroquine alone, 54/271 (19.9% [95% CI, 15.2%-24.7%]), azithromycin alone, 21/211 (10.0% [95% CI, 5.9%-14.0%]), and neither drug, 28/221 (12.7% [95% CI, 8.3%-17.1%]). In adjusted Cox proportional hazards models, compared with patients receiving neither drug, there were no significant differences in mortality for patients receiving hydroxychloroquine + azithromycin (HR, 1.35 [95% CI, 0.76-2.40]), hydroxychloroquine alone (HR, 1.08 [95% CI, 0.63-1.85]), or azithromycin alone (HR, 0.56 [95% CI, 0.26-1.21]). In logistic models, compared with patients receiving neither drug cardiac arrest was significantly more likely in patients receiving hydroxychloroquine + azithromycin (adjusted OR, 2.13 [95% CI, 1.12-4.05]), but not hydroxychloroquine alone (adjusted OR, 1.91 [95% CI, 0.96-3.81]) or azithromycin alone (adjusted OR, 0.64 [95% CI, 0.27-1.56]), . In adjusted logistic regression models, there were no significant differences in the relative likelihood of abnormal electrocardiogram findings. Among patients hospitalized in metropolitan New York with COVID-19, treatment with hydroxychloroquine, azithromycin, or both, compared with neither treatment, was not significantly associated with differences in in-hospital mortality. However, the interpretation of these findings may be limited by the observational design. This study examines associations between use of hydroxychloroquine, azithromycin, or both and in-hospital mortality, ECG changes, and cardiac arrest among patients with COVID-19 hospitalized in the metropolitan New York area in March 2020.

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Why inequality could spread COVID-19

Faheem Ahmed, Na'eem Ahmed, Christopher Pissarides … (2020)

Pandemics rarely affect all people in a uniform way. The Black Death in the 14th century reduced the global population by a third, with the highest number of deaths observed among the poorest populations. 1 Densely populated with malnourished and overworked peasants, medieval Europe was a fertile breeding ground for the bubonic plague. Seven centuries on—with a global gross domestic product of almost US$100 trillion—is our world adequately resourced to prevent another pandemic? 2 Current evidence from the coronavirus disease 2019 (COVID-19) pandemic would suggest otherwise. Estimates indicate that COVID-19 could cost the world more than $10 trillion, 3 although considerable uncertainty exists with regard to the reach of the virus and the efficacy of the policy response. For each percentage point reduction in the global economy, more than 10 million people are plunged into poverty worldwide. 3 Considering that the poorest populations are more likely to have chronic conditions, this puts them at higher risk of COVID-19-associated mortality. Since the pandemic has perpetuated an economic crisis, unemployment rates will rise substantially and weakened welfare safety nets further threaten health and social insecurity. Working should never come at the expense of an individual's health nor to public health. In the USA, instances of unexpected medical billings for uninsured patients treated for COVID-19 and carriers continuing to work for fear of redundancy have already been documented. 4 Despite employment safeguards recently being passed into law in some high-income countries, such as the UK and the USA, low-income groups are wary of these assurances since they have experience of long-standing difficulties navigating complex benefits systems, 4 and many workers (including the self-employed) can be omitted from such contingency plans. The implications of inadequate financial protections for low-wage workers are more evident in countries with higher levels of extreme poverty, such as India. In recent pandemics, such as the Middle East respiratory syndrome, doctors were vectors of disease transmission due to inadequate testing and personal protective equipment. 5 History seems to be repeating itself, with clinicians comprising more than a tenth of all COVID-19 cases in Spain and Italy. With a projected global shortage of 15 million health-care workers by 2030, governments have left essential personnel exposed in this time of need. Poor populations lacking access to health services in normal circumstances are left most vulnerable during times of crisis. Misinformation and miscommunication disproportionally affect individuals with less access to information channels, who are thus more likely to ignore government health warnings. 6 With the introduction of physical distancing measures, household internet coverage should be made ubiquitous. The inequitable response to COVID-19 is already evident. Healthy life expectancy and mortality rates have historically been markedly disproportionate between the richest and poorest populations. The full effects of COVID-19 are yet to be seen, while the disease begins to spread across the most fragile settings, including conflict zones, prisons, and refugee camps. As the global economy plunges deeper into an economic crisis and government bailout programmes continue to prioritise industry, scarce resources and funding allocation decisions must aim to reduce inequities rather than exacerbate them.

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Author and article information

Contributors

Jesem Orellana:

ORCID: https://orcid.org/0000-0002-5607-2615

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: SupervisionRole: VisualizationRole: Writing – review & editing

Nadège Jacques: Role: Project administrationRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Daniel Gray Paschoal Leventhal:

ORCID: https://orcid.org/0000-0001-5229-5697

Role: Project administrationRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Lihsieh Marrero: Role: Project administrationRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Lina Sofía Morón-Duarte: Role: Project administrationRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Rosely Sichieri: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS One

Journal ID (publisher-id): plos

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 20 October 2022

Publication date Collection: 2022

Publication date PMC-release: 20 October 2022

Volume: 17

Issue: 10

Electronic Location Identifier: e0275333

Affiliations

[1 ] Leônidas and Maria Deane Institute, Oswaldo Cruz Foundation, Manaus, Amazonas, Brazil

[2 ] Postgraduate Program in Epidemiology, Department of Social Medicine, Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil

[3 ] Independent Researcher, Takoma Park, Maryland, United States of America

[4 ] Department of Nursing, Amazonas State University, Manaus, Amazonas, Brazil

[5 ] Global Institute of Clinical Excellence, Keralty, Bogotá, Distrito Capital, Colombia

[6 ] Translational Research Group, Sanitas University Foundation, Bogotá, Distrito Capital, Colombia

State University of Rio de janeiro, BRAZIL

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: jesem.orellana@ 123456gmail.com

Author information

Jesem Orellana https://orcid.org/0000-0002-5607-2615

Daniel Gray Paschoal Leventhal https://orcid.org/0000-0001-5229-5697

Article

Publisher ID: PONE-D-22-12863

DOI: 10.1371/journal.pone.0275333

PMC ID: 9584504

PubMed ID: 36264994

SO-VID: e9a4e6ef-4e47-4fa0-9ddb-e78063adf469

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 2 May 2022

Date accepted : 14 September 2022

Page count

Figures: 3, Tables: 2, Pages: 15

Funding

The authors gratefully acknowledge support from the Fundação de Amparo à Pesquisa do Estado do Amazonas and Fundação Oswaldo Cruz, (project grant 04/2022/FIOCRUZ/FAPEAM/FAPERO) – Programa de Apoio à Pesquisa de Inovação Tecnológica – Inovação na Amazônia, awarded to JO and LM.

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Data Availability The data underlying the results presented in the study are available from https://datasus.saude.gov.br/informacoes-de-saude-tabnet/.

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Excess maternal mortality in Brazil: Regional inequalities and trajectories during the COVID-19 epidemic

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Abstract

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Novel Coronavirus Disease COVID-19

Most cited references 56

Observational Study of Hydroxychloroquine in Hospitalized Patients with Covid-19

Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State

Why inequality could spread COVID-19

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