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.

Maternal diet and interactions with nutritional evaluation during pregnancy.

This narrative review aims to describe the knowledge regarding nutritional evaluation and monitoring in pregnant women. We discuss care provided by non-specialists in nutrition, regarding dietary information and risks during pregnancy, from a theoretical or conceptual viewpoint. A narrative review was conducted following a literature search when scientific databases were investigated, including SciELO, LILACS, Medline, PubMed, theses, government reports, books, and chapters in books. Finally, the material was fully read, categorized, and critically analyzed. National and international protocols of prenatal nutritional care were included and discussed. Different protocols describe the complexity of evaluating and monitoring nutrition among pregnant women during the prenatal period according to each country. The understanding of social conditions and eating habits has an important role in providing nutritional advice during pregnancy. The lack of dietitians in care overwhelms the healthcare workers and characterizes a missed opportunity. Therefore, it is important to consider rapid support tools that can track adverse nutritional status, and ways to recommend a diet that meets eating habit dynamics, according to the reality of each public health system.

Measuring resilience and stress during pregnancy and its relation to vulnerability and pregnancy outcomes in a nulliparous cohort study.

BACKGROUND: Resilience reflects coping with pregnancy-specific stress, including physiological adaptations of the maternal organism or factors arising from the socioeconomic context, such as low income, domestic violence, drug and alcohol use, lack of a support network and other vulnerability characteristics. Resilience is a dynamic characteristic that should be comparatively evaluated within a specific context; its association with perceived stress and social vulnerability during pregnancy is still not fully understood. This study aimed at exploring maternal resilience, perceived stress and social vulnerability during pregnancy and its associated factors and outcomes. METHODS: Prospective multicenter cohort study of nulliparous women in Brazil determining resilience (Resilience Scale; RS) and stress (Perceived Stress Scale; PSS) at 28 weeks of gestation (± 1 week). Resilience and stress scores were compared according to sociodemographic characteristics related to maternal/perinatal outcomes and social vulnerability, defined as having low level of education, being adolescent, without a partner or ethnicity other than white. RESULTS: We included 383 women who completed the RS and PSS instruments. Most women showed low resilience scores (median: 124.0; IQR 98-143). Women with a low resilience score (RS < 125) were more likely from the Northeast region, adolescents, other than whites, did not study or work, had a low level of education, low family income and received public antenatal care. Higher scores of perceived stress were shown in the Northeast, other than whites, at low levels of education, low annual family income and public antenatal care. Pregnant women with low resilience scores (n = 198) had higher perceived stress scores (median = 28) and at least one vulnerability criterion (n = 181; 91.4%). CONCLUSION: Our results reinforce the role of resilience in protecting women from vulnerability and perceived stress. It may prevent complications and build a positive experience during pregnancy.

A conceptual framework for nutritional evaluation, screening, and monitoring of pregnant women: Evidence from a Brazilian cohort of nulliparous women.

The present review comes from five previous studies of a multicenter cohort of nulliparous pregnant women from different regions of Brazil. The first study showed a wide difference in consumption of industrialized foods among women from the south and southeast regions compared with northeastern women who chose to eat a healthier diet with fresh natural food. The second investigation intended to understand maternal eating habits, where five dietary patterns were identified: two considered healthy and three with excess protein, ultra-processed foods, fats, and sweets. Considering some barriers to classifying nutrition status during prenatal care, when data on pre-pregnancy weight is unknown, the third study developed a tool to identify three levels of risk for each gestational age range, assessed by measuring arm circumference. Applying those new tools, the associations between maternal nutrition and pregnancy outcomes were investigated: prematurity, pre-eclampsia, gestational diabetes mellitus, and small-for-gestational-age infants. From these analyses, a predictive model was developed indicating that obesity, non-white color, and dietary pattern with excess protein consumption were associated with a greater probability of adverse pregnancy outcomes. Moreover, the potential of the intergenerational influence of head circumference as a proxy for maternal nutrition was analyzed. Using a Path Analysis method, the model was evidenced by different socioeconomic variables. Finally, understanding the complexity of the nutritional assessment, the present conceptual framework was proposed for nutritional assessment, and tracking and monitoring of pregnant women.

Head circumference as an epigenetic risk factor for maternal nutrition.

Nutrition indicators for malnutrition can be screened by many signs such as stunting, underweight or obesity, muscle wasting, and low caloric and nutrients intake. Those deficiencies are also associated with low socioeconomic status. Anthropometry can assess nutritional status by maternal weight measurements during pregnancy. However, most studies have focused primarily on identifying changes in weight or Body Mass Index (BMI), and their effects on neonatal measures at present time. Whereas head circumference (HC) has been associated with nutrition in the past. When the mother was exposed to poor nutrition and unfavorable social conditions during fetal life, it was hypothesized that the intergenerational cycle was potentially mediated by epigenetic mechanisms. To investigate this theory, maternal head circumference (MHC) was associated with neonatal head circumference (NHC) in pregnant women without preexisting chronic conditions, differentiated by sociodemographic characteristics. A multiple linear regression model showed that each 1 cm-increase in MHC correlated with a 0.11 cm increase in NHC (ß95% CI 0.07 to 0.15). Notwithstanding, associations between maternal and neonatal anthropometrics according to gestational age at birth have been extensively explained. Path analysis showed the influence of social status and the latent variable was socioeconomic status. A model of maternal height and head circumference was tested with effects on neonatal HC. The social variable lacked significance to predict neonatal HC in the total sample (p = 0.212) and in the South/Southeast (p = 0.095), in contrast to the Northeast (p = 0.047). This study highlights the potential intergenerational influence of maternal nutrition on HC, suggesting that maternal nutrition may be more relevant in families with major social vulnerability.

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.

Profile of calories and nutrients intake in a Brazilian multicenter study of nulliparous women.

OBJECTIVE: To assess the calorie intake and nutritional content of the maternal diet in regions with different culinary traditions and typical foods, and to understand the nutritional profile so as to provide information about the consumption of this population and promote maternal and perinatal health. METHODS: From a cohort of 1145 pregnant women with diverse socio-backgrounds we analyzed the dietary characteristics profile according to three guidelines and compared the differences between regions of Brazil. RESULTS: Women from the northeast had the lowest level of income, occupation, education, and age (P < 0.001). Intakes of unprocessed/minimally processed foods and processed foods were more prevalent in women from the northeast than in southern/southeastern women (P < 0.001). The consumption of dairy products and vegetables was less than the recommended intake, with lower intake in southern/southeastern women (P < 0.001). This study showed a lower consumption of dairy and vegetables, with a shortfall of vitamins K and D, iron, calcium, folate, magnesium, and chromium from natural and fortified foods. We observed a greater consumption of unprocessed or minimally processed food in women from the northeast of Brazil. CONCLUSION: Our findings indicate the importance of differentiating the source of calorie intake between regional nutritional guidance and the diversity of local cuisine.

Agreement between the short and long versions of the Resilience Scale: A validation among the obstetric population according to vulnerability status.

OBJECTIVE: To compare the 14-item Resilience Scale (RS-14) and the original 25-item scale (RS-25) in the obstetric population, including vulnerable and non-vulnerable women. METHODS: A Brazilian prospective cohort study was conducted of nulliparous singleton pregnant women from March 2018 to March 2020. Women who completed the RS-25 at 27-29 weeks of pregnancy were included in the analysis. RS-25 and RS-14 scores were converted to comparable scales of 0-100. Medians, standard deviations, and centiles between versions were compared for the general, vulnerable, and non-vulnerable populations. Correlation, concordance, and internal consistency and reliability analyses were performed. P < 0.05 was considered statistically significant. RESULTS: In total, 381 women who completed the RS-25 were included. Medians of RS-14 and RS-25 scores were significantly different (73.4 and 70.8, respectively; P < 0.001), regardless of the vulnerability status. The RS-14 showed a high correlation (Pearson´s correlation coefficient of -0.379 (P-value < 0.001)), but no agreement (Pitman's test of difference in variance: r = 0.422; P < 0.001) with the RS-25 version. RS-14 showed high internal consistency and reliability with only one component (Variance of 59.82%, Cronbach's Alpha 0.947). CONCLUSION: The RS-14 may overestimate the RS-25 score and different domains may not be assessed by the short version. The psychometric properties of the RS-14 and the clinical relevance of the variation between versions require further evaluation.

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.

Maternal Nutrition Status Associated with Pregnancy-Related Adverse Outcomes.

Although maternal nutrition has an impact on fetal development and gestational outcome, tracking maternal nutrition in outpatient practice is still complex and involves proper technical capacitation in this area. Nevertheless, the association between nutritional variables may broaden the ability to predict the occurrence of gestational disorders and prevention management. We aimed to identify factors that could indicate the probability of adverse outcomes in mid-pregnancy. From a cohort of 1165 nulliparous pregnant women without any previous disease, the nutritional status was assessed by body mass index (BMI) and mid-upper arm circumference (MUAC), associated with dietary patterns and sociodemographic characteristics. Two predictive models with nutritional status for screening the occurrence of adverse outcomes of preterm birth, gestational diabetes mellitus, small-for-gestational-age newborns and preeclampsia were developed. The odds of adverse outcomes were higher in non-white (p < 0.05) obese women and with high protein consumption. There was no significant difference between the models, with an overall accuracy of 63% for both models and a probability of success in predicting adverse outcomes (BMI = 61%, MUAC = 52%). This study of Brazilian pregnant nulliparous women offers two possible options for early tracking of adverse gestational outcomes that should be further externally validated.

The food patterns of a multicenter cohort of Brazilian nulliparous pregnant women.

Assessment of human nutrition is a complex process, in pregnant women identify dietary patterns through mean nutrient consumption can be an opportunity to better educate women on how to improve their overall health through better eating. This exploratory study aimed to identify a posteriori dietary patterns in a cohort of nulliparous pregnant women. The principal component analysis (PCA) technique was performed, with Varimax orthogonal rotation of data extracted from the 24-h dietary recall, applied at 20 weeks of gestation. We analysed 1.145 dietary recalls, identifying five main components that explained 81% of the dietary pattern of the sample. Dietary patterns found were: Obesogenic, represented by ultra-processed foods, processed foods, and food groups rich in carbohydrates, fats and sugars; Traditional, most influenced by natural, minimally processed foods, groups of animal proteins and beans; Intermediate was similar to the obesogenic, although there were lower loads; Vegetarian, which was the only good representation of fruits, vegetables and dairy products; and Protein, which best represented the groups of proteins (animal and vegetable). The obesogenic and intermediate patterns represented over 37% of the variation in food consumption highlighting the opportunity to improve maternal health especially for women at first mothering.

Proposal of MUAC as a fast tool to monitor pregnancy nutritional status: results from a cohort study in Brazil.

OBJECTIVE: In Brazil, although the assessment of maternal nutritional status is recommended using body mass index (BMI), this is only possible in settings adequately prepared. Midupper arm circumference (MUAC) is another biological variable identified as a tool for rapid assessment of nutritional status that is correlated with BMI. Therefore, we aim to surrogate BMI by MUAC cut-offs for rapid screening of maternal nutritional status starting at midpregnancy. DESIGN: Analysis of the multicentre cohort study entitled 'Preterm SAMBA' using an approach of validation of diagnostic test. SETTING: Outpatient prenatal care clinics from five tertiary maternity hospitals from three different Brazilian regions. PARTICIPANTS: 1165 pregnant women attending prenatal care services from 2015 to 2018 and with diverse ethnic characteristics who were enrolled at midpregnancy and followed in three visits at different gestational weeks. PRIMARY AND SECONDARY OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values, likelihood ratio and accuracy of MUAC being used instead of BMI for the assessment of nutritional status of women during pregnancy. RESULTS: We found a strong correlation between MUAC and BMI, in the three set points analysed (r=0.872, 0.870 and 0.831, respectively). Based on BMI categories of nutritional status, we estimated the best MUAC cut-off points, finding measures according to each category: underweight <25.75 cm (19-39 weeks); overweight 28.11-30.15 cm (19-21 weeks), 28.71-30.60 cm (27-29 weeks) and 29.46-30.25 cm (37-39 weeks); and obese >30.15 cm (19-21 weeks), >30.60 cm (27-29 weeks) and >30.25 cm (37-39 weeks) per gestational week. Therefore, we defined as adequate between 25.75-28.10 cm (19-21 weeks), 25.75-28.70 cm (27-29 weeks) and 25.75-29.45 cm (37-39 weeks) of MUAC. CONCLUSION: We conclude that MUAC can be useful as a surrogate for BMI as a faster screening of nutritional status in pregnant women.

"Babies born early?" - silences about prematurity and their consequences.

BACKGROUND: The principal aim of this study was to understand how communication between parents and health professionals concerning prematurity occurs, from delivery to admission to the neonatal Intensive Care Unit. METHODS: This is an exploratory, descriptive study with a qualitative methodology. Data were collected using tape-recorded and Focal Groups technique interview with mothers of premature newborns and health professionals involved in caring for preterm infants, at southeast Brazil. RESULTS: The word "premature" was not said or heard during prenatal care. From the narratives, it was observed that there was a lack of information available to pregnant women about preterm birth, failure in medical care regarding signs and symptoms reported by pregnant women, and lack of communication between the medical teams, mothers and family during delivery and Neonatal Intensive Care Unit (NICU) admission. CONCLUSION: There is a fine line between born too soon and die too soon, that increases stress, fear and distance impacting negatively over communication between mothers and health professionals during antenatal care, childbirth and NICU admission.