Maternal mortality and COVID-19.

OBJECTIVE: The aim of this study was to collect and analyze data from different sources to have a general overview of COVID-19-related maternal deaths in Brazil, as well as to compare data with worldwide reports. STUDY DESIGN: We systematically searched data about COVID-19 maternal deaths from the Brazilian Ministry of Health surveillance system, State Departments of Health epidemiological reports, and media coverage. Data about timing of symptom onset and death (pregnancy or postpartum), gestational age, mode of birth, maternal age, comorbidities and/or risk factors, date of death, and place of death were retrieved when available. RESULTS: We identified 20 COVID-19-related maternal deaths, age range 20-43 years. Symptoms onset was reported as on pregnancy for 12 cases, postpartum for 3 cases, and during the cesarean section for 1 case (missing data for 4). In 16 cases, death occurred in the postpartum period. At least one comorbidity or risk factor was present in 11 cases (missing data for 4). Asthma was the most common risk factor (5/11). Ten cases occurred in the Northeast region, and nine cases occurred in the Southeast region (5 of them in São Paulo, the first epicenter of COVID-19 in the country). CONCLUSIONS: To the best of our knowledge, this is the largest available series of maternal deaths due to COVID-19. Barriers to access healthcare, differences in pandemic containment measures in the country and high prevalence of concomitant risk factors for COVID-19 severe disease may play a role in the observed disparity compared to worldwide reports on maternal outcomes.

COVID-19-related deaths among women of reproductive age in Brazil: The burden of postpartum.

OBJECTIVE: To compare risk of death due to COVID-19 among pregnant, postpartum, and non-pregnant women of reproductive age in Brazil, using the severe acute respiratory syndrome surveillance system (SARS-SS). METHODS: A secondary analysis was performed of the Brazilian official SARS-SS, with data retrieved up to August 17, 2020. Cases were stratified by pregnancy status, risk factors or co-morbidities, and outcome (death or recovery). Multiple logistic regression was employed to examine associations between independent variables and risk of death. RESULTS: A total of 24 805 cases were included, with 3129 deaths (12.6%), including 271 maternal deaths. Postpartum was associated with increased risk of death, admission to the intensive care unit (ICU), and mechanical ventilation. Co-morbidities with higher impact on case fatality rate among non-obstetric cases were cancer and neurological and kidney diseases. Among pregnant women, cancer, diabetes mellitus, obesity, and rheumatology diseases were associated with risk of death. In the postpartum subgroup, age over 35 years and diabetes mellitus were independently associated with higher chance of death. CONCLUSION: Postpartum was associated with worse outcomes among the obstetric population, despite lower risk of dying without accessing ICU care. Non-pregnant women with cancer, neurological diseases, and kidney diseases have a higher risk of death due to COVID-19.

Risk factors for adverse outcomes among pregnant and postpartum women with acute respiratory distress syndrome due to COVID-19 in Brazil.

OBJECTIVE: To evaluate whether clinical and social risk factors are associated with negative outcomes for COVID-19 disease among Brazilian pregnant and postpartum women. METHODS: A secondary analysis was conducted of the official Acute Respiratory Syndrome Surveillance System database. Pregnant and postpartum women diagnosed with COVID-19 ARDS until July 14, 2020, were included. Adverse outcomes were a composite endpoint of either death, admission to the intensive care unit (ICU), or mechanical ventilation. Risk factors were examined by multiple logistic regression. RESULTS: There were 2475 cases of COVID-19 ARDS. Among them, 23.8% of women had the composite endpoint and 8.2% died. Of those who died, 5.9% were not hospitalized, 39.7% were not admitted to the ICU, 42.6% did not receive mechanical ventilation, and 25.5% did not have access to respiratory support. Multivariate analysis showed that postpartum period, age over 35 years, obesity, diabetes, black ethnicity, living in a peri-urban area, no access to Family Health Strategy, or living more than 100 km from the notification hospital were associated with an increased risk of adverse outcomes. CONCLUSION: Clinical and social risk factors and barriers to access health care are associated with adverse outcomes among maternal cases of COVID-19 ARDS in Brazil.

Factors Associated with Preference for Vaginal Birth among Undergraduate Students from Southern Brazil.

BACKROUND: Cesarean rates in Brazil have reached over 50 percent of all births. Multiple factors have been studied aiming to explain these rates. Mode of delivery preferences among university students may provide insights into strategies to reduce those numbers. METHODS: A cross-sectional study was conducted enrolling students who attended Health Sciences and Human Sciences undergraduate programs in 2013. Participants answered a semi-structured questionnaire about which mode of delivery they considered the "best" (less risky and more beneficial) and the "preferred" mode (the one they would choose for themselves or their partners). Pearson chi-square was used to assess association among variables. Multiple regression analysis identified independent factors associated with the outcome measures. RESULTS: Among the 797 students who provided complete responses (76% response rate), the mean age was 22.6 years, 61.6 percent were female, 2.6 percent had previous pregnancies, and 56.7 percent were born by cesarean. Vaginal birth was chosen as the "best" mode of delivery by 91.2 percent, and the "preferred" mode by 75.5 percent of students. Being male, born vaginally, and a Health Sciences student was associated with a preference for vaginal birth. Being a Health Sciences student and born vaginally was associated with considering vaginal birth the "best" mode of delivery. CONCLUSIONS: Our findings indicate that the recognition of the benefits of vaginal birth do not always translate into a personal preference for vaginal birth. The student's own mode of birth was a strong predictor of their preferences for mode of delivery.

Cost analysis of multiple sclerosis in Brazil: a cross-sectional multicenter study.

BACKGROUND: Multiple sclerosis (MS) is a central nervous system disease associated with irreversible progression of disability, which imposes a substantial socioeconomic onus. The objective of this study was to determine the economic impact of multiple sclerosis from the Brazilian household and healthcare system perspectives. Secondary objectives were to assess the impact of fatigue on daily living and health-related quality of life (HRQL) of MS patients. METHODS: This is a cross-sectional study in which Brazilian eligible patients attending eight major MS specialized sites answered an interview capturing data on demographics, disease characteristics and severity, comorbidities, resource utilization, fatigue, utilities and health-related quality of life from November/2011 to May/2012 . Costs were assessed considering a prevalence-based approach within 1 year of resource consumption and were estimated by multiplying the amount used by the corresponding unit cost. Patients were classified as having mild, moderate or severe disability according to the Expanded Disability Status Scale (EDSS). RESULTS: In total, 210 patients who met eligibility criteria were included, 40 % had mild, 43 % moderate and 16 % severe disability; disability level was missing for 1 %. The average total direct cost per year was USD 19,012.32 (SD = 10,465.96), and no statistically significant differences were not observed according to MS disability level (p = 0.398). The use of disease modifying therapies (DMTs) corresponded to the majority of direct expenditures, especially among those patients with lower levels of disability, representing around 90 % of total costs for mild and moderate MS patients. It was also observed that expenses with medical (except DMTs) and non-medical resources are higher among patients with more severe disease. Worsening disability also had an important influence on health-related quality of life and self-perceived impact of fatigue on daily living. CONCLUSION: Our data demonstrates the significant economic impact of MS on both Brazilian household and health system, in terms of DMTs and other disease management costs. When patients move upwards on the disease severity scale, costs with health resources other than drugs are significantly increased.

Health care resource use and costs in opioid-treated patients with and without constipation in Brazil.

OBJECTIVE: To estimate the prevalence of constipation concomitant to opioid treatment and related resource use and costs from the private payer perspective. METHODS: In this retrospective database analysis, patients receiving opioid therapy were identified from a longitudinal insurance claims database. An algorithm was used to identify patients receiving opioid therapy with coincident constipation-related claims according to ICD-10 codes, targeted procedures, and opioid use criteria. Resource use and costs were determined for these individuals and compared with patients receiving opioid therapy without constipation, without opioid therapy with constipation, and without both conditions. Results were compared using analysis of variance with a significance level of 0.05. RESULTS: A total of 23,313 patients were classified as opioid-treated patients (2.2%) and 6678 of them had events related to constipation (29.0%). Compared with opioid-treated patients without constipation, incremental mean total costs per month per patient were 261.18 BRL (P < 0.001). The average cost per month for opioid-related constipation patients was 787.84 BRL, significantly higher than other patients (P < 0.001 for all comparisons). Among cancer patients, 24.4% was receiving opioids and 27.0% of those had constipation-related claims. As expected, the opioid therapy prevalence was significantly higher when compared to all patients (2.2% vs. 24.4%, P < 0.001). Cancer patients had, in average, higher costs than did noncancer patients in all four subgroups. CONCLUSIONS: Patients with constipation coincident with opioid treatment exhibited a significantly higher economic burden than did patients without the condition. These results indicate that reducing opioid-induced constipation could lead to potential cost savings for the health care system.