Pregnant women who are hospitalised with Covid-19 in sub-Saharan Africa are dying at a rate far greater than pregnant people without Covid-19 and non-pregnant people with Covid-19, according to a new multicenter study encompassing six African countries. The research was published today in Clinical Infectious Diseases and led by an infectious diseases epidemiologist at Stellenbosch University's Faculty of Medicine and Health Sciences (FMHS) and University of Pittsburgh School of Public Health.

The effects of Covid-19 on pregnancy have been studied in detail in higher income countries, such as the United States, but studies of similar size and scope are lacking in low- and middle-income countries and non-Western settings. The new findings confirm that pregnant people are at higher risk of complications and death from Covid-19 and, therefore, should be prioritized with other high-risk people for Covid-19 vaccination in sub-Saharan Africa.

“Our findings indicate that hospitalised pregnant women with Covid-19 in sub-Saharan Africa have two  to five times greater risk of needing intensive care and dying than uninfected, hospitalised pregnant women," said lead author Jean B. Nachega, MD, PhD, MPH, associate professor of infectious diseases and microbiology and epidemiology at the FMHS and Pitt Public Health. “We must urgently prioritise pregnant women among at-risk populations in Covid-19 vaccine programs in Africa."

The large study looked at outcomes of over 1 300 female patients of child-bearing age who were hospitalised between March 2020 and March 2021 in one of six countries: the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa and Uganda. Specifically, this study looked at three categories: pregnant women with Covid-19, non-pregnant women with Covid-19 and pregnant women without Covid-19.

Researchers found that the rates of intensive care unit (ICU) admission and use of supplemental oxygen were at least two-fold higher and the death toll increased five-fold in the pregnant women with SARS-CoV-2.

Sub-Saharan Africa also has higher rates of tuberculosis (TB) and HIV than developed countries such as the United States, and published studies on Covid-19 among people with these chronic infections have had conflicting results, so the team also investigated the impact of these infections on their study population. Among the participants, both pregnant and non-pregnant women with HIV or a prior history of TB had a two-fold increased risk of ICU admission.

“Pregnant women in the third trimester were more severely affected than women during early pregnancy when they developed Covid-19 pneumonia – this is probably due to the impact of the uterus and growing baby on the mother's respiratory function," said study obstetric principal investigator, Dr Eduard Langenegger, Obstetric Critical Care and Maternal Foetal Medicine Specialist at Tygerberg Hospital and Stellenbosch University. Early on in the pandemic, Tygerberg Hospital established a dedicated Obstetrics Covid-19 Unit to manage pregnant women with complicated Covid-19. “Nearly a third of women admitted with Covid-19 pneumonia had life threatening disease and required respiratory support and critical care, and sadly many died.

Langenegger continued: “Covid-19 also affects the unborn baby, and they are more likely to be born prematurely and develop other complications. When the mother becomes unstable, her unborn baby can develop hypoxia [low oxygen levels] which can result in brain damage and intra-uterine death."

Nachega noted recent progress on increasing the Covid-19 vaccine supply in Africa but emphasized that Covid-19 vaccine hesitancy and misinformation about public health guidance is a global issue, and Africa is no exception.  In an editorial published alongside the study, Nachega and fellow researchers emphasized that targeting Covid-19 vaccinations to this population is key in improving mother and infant outcomes.

“Covid-19 vaccine hesitancy and low vaccine uptake in pregnancy include misinformation and disinformation promoted on social media and other platforms, which mislead the public about side effects, such as infertility and potential foetal harm," Nachega said. “Along with devoting resources to promoting vaccination, we must also work to stop the spread of misinformation."

Langenegger concluded: “Complications, including death, is much higher in pregnant women with Covid-19. Vaccination is safe and saves mothers and babies. It is of utmost importance for eligible pregnant women to get vaccinated to protect themselves and their babies."

Additional investigators of this study are members of the African Forum for Research and Education in Health Covid-19 Research Collaboration on Covid-19 and Pregnancy and are listed in the Clinical Infectious Diseases article.

This research was supported by National Institutes of Health Fogarty International Centre grant 1R25TW011217-01. 

Photo caption: Prof Jean Nachega and Dr Eduard Langenegger.