Article Text

Global variations in the burden of SARS-CoV-2 infection and its outcomes in pregnant women by geographical region and country’s income status: a meta-analysis
  1. Jameela Sheikh1,
  2. Heidi Lawson1,
  3. John Allotey2,
  4. Magnus Yap1,
  5. Rishab Balaji1,
  6. Tania Kew1,
  7. Elena Stallings3,4,
  8. Dyuti Coomar2,
  9. Andrea Gaetano-Gil3,4,
  10. Javier Zamora2,3,
  11. Shakila Thangaratinam2,5
  12. on behalf of the PregCOV-19 Living Systematic Review Consortium
    1. 1College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
    2. 2Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
    3. 3Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
    4. 4CIBER Epidemiology and Public Health, Madrid, Spain
    5. 5Birmingham Women's Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
    1. Correspondence to Professor Shakila Thangaratinam; s.thangaratinam.1{at}


    Introduction The prevalence of COVID-19 and its impact varied between countries and regions. Pregnant women are at high risk of COVID-19 complications compared with non-pregnant women. The magnitude of variations, if any, in SARS-CoV-2 infection rates and its health outcomes among pregnant women by geographical regions and country’s income level is not known.

    Methods We performed a random-effects meta-analysis as part of the ongoing PregCOV-19 living systematic review (December 2019 to April 2021). We included cohort studies on pregnant women with COVID-19 reporting maternal (mortality, intensive care admission and preterm birth) and offspring (mortality, stillbirth, neonatal intensive care admission) outcomes and grouped them by World Bank geographical region and income level. We reported results as proportions with 95% confidence intervals (CI).

    Results We included 311 studies (2 003 724 pregnant women, 57 countries). The rates of SARS-CoV-2 infection in pregnant women varied significantly by region (p<0.001) and income level (p<0.001), with the highest rates observed in Latin America and the Caribbean (19%, 95% CI 12% to 27%; 13 studies, 38 748 women) and lower-middle-income countries (13%, 95% CI 6% to 23%; 25 studies, 100 080 women). We found significant differences in maternal and offspring outcomes by region and income level. Lower-middle-income countries reported significantly higher rates of maternal mortality (0.68%, 95% CI 0.24% to 1.27%; 3 studies, 31 136 women), intensive care admission (4.53%, 95% CI 2.57% to 6.91%; 54 studies, 23 420 women) and stillbirths (1.09%, 95% CI 0.48% to 1.88%; 41 studies, 4724 women) than high-income countries. COVID-19 complications disproportionately affected South Asia, which had the highest maternal mortality rate (0.88%, 95% CI 0.16% to 1.95%; 17 studies, 2023 women); Latin America and the Caribbean had the highest stillbirth rates (1.97%, 95% CI 0.9% to 3.33%; 10 studies, 1750 women).

    Conclusion The rates of SARS-CoV-2 infection in pregnant women vary globally, and its health outcomes mirror the COVID-19 burden and global maternal and offspring inequalities.

    PROSPERO registration number CRD42020178076.

    • COVID-19
    • Maternal health

    Data availability statement

    No data are available. No additional data are available.

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    • JS and HL are joint first authors.

    • Handling editor Seye Abimbola

    • Twitter @medstudentjam, @joallotey, @javierza67, @thangaratinam

    • Collaborators PregCOV-19 Living Systematic Review Consortium: Silvia Fernández-García, Megan Littmoden, Millie Manning, Adeolu Banjoko, Dengyi Zhou, Shruti Attarde, Ankita Gupta, Kehkashan Ansari, Yasmin King, Gurimaan Sandhu, Damilola Akande, Dharshini Sambamoorthi, Anoushka Ramkumar, Helen Fraser, Meghnaa Hebbar, Sophie Maddock, Tanisha Rajah, Alya Khashaba, Kathryn Barry, Massa Mamey, Wentin Chen, Halimah Khalil, Elena Kostova, Elena Stallings, Shaunak Chatterjee, Luke Debenham, Anna Clavé Llavall, Anushka Dixit, Siang Ing Lee, Xiu Qiu, Mingyang Yuan, Dyuti Coomar, Madelon van Wely, Elizabeth van Leeuwen, Heinke Kunst, Asma Khalil, Simon Tiberi, Vanessa Brizuela, Nathalie Broutet, Edna Kara, Caron Rahn Kim, Anna Thorson, Ramón Escuriet, Olufemi T Oladapo, Lynne Mofenson, Van T Tong, Sascha Ellington, Gianfranco Spiteri, Julien Beaute, Uma Ram, Ajith S Nair, Pura Rayco-Solon, and Hector Pardo-Hernandez.

    • Contributors ST and JA conceptualised the study. JS, HL, RB, MY and TK selected the studies. JA, JS, HL, MY and RB extracted the data. JS, HL and JZ conducted the analyses. JS and HL are joint first authors. All coauthors contributed to the writing of the manuscript and approved the final version. ST, JA and JZ are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

    • Funding The main analysis of the PregCOV-19 Living Systematic Review Consortium was partially funded by the German Federal Ministry of Health (BMG) COVID-19 Research and Development support to the World Health Organization (WHO) and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization, supplementing the work undertaken for this project.

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    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

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