In addition to causing relevant changes in the global routine, the COVID-19 pandemic
status announced and recognized by the World Health Organization (WHO) on March 11,
2020, made it clear that no country was ready to face an infectious disease that spread
rapidly and involved objective risk of death. The retrospective assessment of the
sequence of events and outcomes over the past 17 months leads us to reflect on what
was done, what could have been done, or what should have been done differently. One
of the great challenges in this context was defining which essential health services
should not undergo continuity solutions. With regard to women's health, part of the
care routine was interrupted due to the emergency situation caused by COVID-19, while
others continued to develop their activities following the health safety protocols.
Reproductive planning services, care to victims of domestic and sexual violence and
oncology stand out among those suffering significant reduction in the offer of services
for diagnosis and treatment, which will certainly bring future and important repercussions
for the health of the population.
In relation to obstetric care specifically, women continued to become pregnant and
have their pregnancies resolved. At the beginning of the pandemic, we feared that
women in the pregnancy-puerperal cycle would acquire SARS CoV-2 and based on the experience
with the influenza epidemic in 2009, would present unfavorable outcomes.
In an environment of insecurity, personal opinions and prescription of treatments
without scientific evidence, COVID-19 promoted an unprecedented public health crisis
that required the development of strategic plans contextualizing clear communication
about the disease and its particularities and judicious allocation of resources. Services
for the care of patients infected with SARS CoV-2 had to be organized to ensure the
safety of patients, health professionals and ancillary staff, including cleaning and
administrative services, among others. In obstetric units, the flow of patients had
to be organized, defining which units would be used to care for patients with COVID-19.
Teams had to be prepared and a strategy integrating the units and teams from different
areas and hospitals was established to allow the synergy of teams for the proper care
provision in a structure with a workforce at maximum capacity.
Although different obstetric care services have been organized in our country and
protocols were developed in accordance with international quality standards, COVID-19
continued to spread, confirming that the disease had a worse evolution among women
in the pregnancy-puerperal cycle. Over time, it was learned that there was greater
demand and need for hospitalization, care in the Intensive Care Unit (ICU), invasive
ventilation and even death, compared with non-pregnant women.
In view of this, the Ministry of Health of Brazil constituted a working group composed
of 17 specialists in the area of women's health from different university institutions
to develop strategies aimed at fighting the pandemic for this population segment,
having as background the reduction of maternal mortality by COVID-19. It was the perfect
partnership between the Ministry of Health and academia! The first challenge overcome
by this group was to standardize care for pregnant and puerperal women with suspicion
or diagnosis of this viral infection, addressing the diagnosis, treatment, attention
to antenatal care, ICU care and, obviously, a care flow model for the health services
attending pregnant and puerperal women affected by this infection. Such a strategy
should be feasible and accessible for adoption in a continental country, with notable
differences in the health and care conditions of its population. Based on the available
scientific evidence, since there was no randomized clinical trial in pregnant women,
and on the expertise of the group that met virtually to discuss the topic each week,
a manual[1] was created.
The second challenge was to expand the information contained in the manual to reach
all services, from north to the south of Brazil and help their adaptation to the new
guidelines, leaving their realities and routines and adapting to the care of women
with a disease hitherto unknown in our country. Real clinical cases started to be
discussed with the different obstetric care services throughout Brazil.[2] The contact with health teams from all states, with exchange of experiences and
learning was relevant to the progress of work. There were ∼160 virtual meetings, twice
a day, five days a week, in all Brazilian states. There was excellent receptivity
from local teams, who shared their difficulties and adopted the recommendations of
the working group.
With case discussions across the country, the working group realized the need for
an effective participation of public universities during the challenge of a health
crisis such as the one caused by the COVID-19 pandemic. Additionally, the group sought
to ensure easier access to information, so that professionals could watch educational
videos during their shifts, according to their needs. In partnership with the Pan
American Health Organization (PAHO), short classes[3] with the main topics of the manual were recorded, creating an easily accessible
video library that could be watched anywhere and, given its practical character, assist
in care.
The manual was updated as knowledge about the disease evolved and the working group
deepened, particularly in studies on the benefits and risks of vaccination for COVID-19
in pregnant and puerperal women, as maternal mortality due to COVID -19 in Brazil
is one of the highest in the world. Thus, based on the available scientific literature,
the working group became convinced that vaccines against COVID-19 could help to change
the reality of such an unfavorable outcome. Data from the Brazilian Obstetric Observatory
COVID-19 (OOBr COVID-19). https://observatorioobstetrico.shinyapps.io/covid_gesta_puerp_br/), updated with data made available in the Information System for the Epidemiological
Surveillance of Influenza (Portuguese acronym: SIVEP-Influenza) of the Ministry Health,
became a valuable resource to be part of the reality of the working group. The OOBr
COVID-19 is part of the Brazilian Obstetric Observatory project, which provides an
interactive and dynamic monitoring platform, scientifically based public data analysis
and the dissemination of quality and relevant information in the area of Maternal
and Child Health. Its data showed us the number of pregnant and puerperal women with
Severe Acute Respiratory Syndrome (SARS), the weekly number of deaths in the country
and the highest risk gestational trimester. These data allowed the working group to
reach a definitive conclusion on the urgent use of the vaccine in pregnant and puerperal
women with or without comorbidities, who should receive the vaccine against COVID-19
at any stage of pregnancy. In this context, the partnership with support of the Gynecology
and Obstetrics Specialty Societies in the country was essential to broaden the debate
and publicize the safety and effectiveness of vaccines during pregnancy and puerperal
period. The Brazilian Federation of Gynecology and Obstetrics Societies - FEBRASGO
constituted a Temporary Specialized National Commission of COVID (Portuguese acronym:
CNET COVID), confirming the lead role of the working group in the national scenario.
As a result of all this work, the vaccination of pregnant and puerperal women was
included in the National Immunization Plan of the Ministry of Health (Portuguese acronym:
PNI-MS) and the results shown in the OOBr Covid-19 demonstrate that the vaccination
of these women was the right decision. Today, we are facing a situation of more hope
for pregnant and puerperal women in the face of the pandemic, as the effects of vaccination
reflected in the reduction of maternal mortality by ∼92% in our country.
An interesting aspect during the discussions of clinical cases with the different
services was that many difficulties for the planned changes were beyond the decision-making
power of health teams, that is, the material needs and changes in procedures were
under the responsibility of local or regional health managers. With the help of the
Oswaldo Cruz Foundation (FIOCRUZ), an institution linked to the Ministry of Health,
meetings of the working group with state managers were held, pointing out the difficulties
observed in the discussions and suggesting changes. The lack of harmony and communication
difficulties in the health network in our country drew attention.
The experience acquired in this working group for a common good, facing a pandemic,
showed that the performance of this group can be a model to be applied to combat maternal
mortality resulting from different causes in our country. In view of this scenario,
our assessment of coping with COVID-19 in Brazil, particularly considering pregnant
and puerperal women, is extremely favorable. Within the limitations inherent in a
developing nation, it was very positive to observe that our response was as adequate
as those observed in countries with more favorable socioeconomic conditions.
Together - Educational Institutions, Ministry of Health, research and the health care
network - we are stronger to overcome the difficulties that Brazil is facing and will
still face. Brazilian pregnant women deserve this care!
