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With the paucity of data available regarding COVID‐19 in pregnancy in low‐ and middle‐income countries (LMICs), near the start of the pandemic, the Global Network for Women's and Children's Health Research, funded by the National Institute of Child Health and Human Development (NICHD), initiated four separate studies to better understand the impact of the COVID‐19 pandemic in eight LMIC sites. These sites included: four in Asia, in Bangladesh, India (two sites) and Pakistan; three in Africa, in the Democratic Republic of the Congo (DRC), Kenya and Zambia; and one in Central America, in Guatemala. The first study evaluated changes in health service utilisation; the second study evaluated knowledge, attitudes and practices of pregnant women in relationship to COVID‐19 in pregnancy; the third study evaluated knowledge, attitude and practices related to COVID‐19 vaccination in pregnancy; and the fourth study, using antibody status at delivery, evaluated changes in antibody status over time in each of the sites and the relationship of antibody positivity with various pregnancy outcomes. Across the Global Network, in the first year of the study there was little reduction in health care utilisation and no apparent change in pregnancy outcomes. Knowledge related to COVID‐19 was highly variable across the sites but was generally poor. Vaccination rates among pregnant women in the Global Network were very low, and were considerably lower than the vaccination rates reported for the countries as a whole. Knowledge regarding vaccines was generally poor and varied widely. Most women did not believe the vaccines were safe or effective, but slightly more than half would accept the vaccine if offered. Based on antibody positivity, the rates of COVID‐19 infection increased substantially in each of the sites over the course of the pandemic. Most pregnancy outcomes were not worse in women who were infected with COVID‐19 during their pregnancies. We interpret the absence of an increase in adverse outcomes in women infected with COVID‐19 to the fact that in the populations studied, most COVID‐19 infections were either asymptomatic or were relatively mild. [ABSTRACT FROM AUTHOR]

Objective: To determine the relation of COVID‐19 symptoms to COVID‐19 antibody positivity among unvaccinated pregnant women in low‐ and middle‐income countries (LMIC). Design: COVID‐19 infection status measured by antibody positivity at delivery was compared with the symptoms of COVID‐19 in the current pregnancy in a prospective, observational cohort study in seven LMICs. Setting: The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR), a prospective, population‐based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (Belagavi and Nagpur sites) and Guatemala. Population: Pregnant women enrolled in the ongoing pregnancy registry at study sites. Methods: Data on COVID‐19 symptoms during the current pregnancy were collected by trained staff between October 2020 and June 2022. COVID‐19 antibody testing was performed on samples collected at delivery. The relation between COVID‐19 antibody positivity and symptoms was assessed using generalised linear models with a binomial distribution adjusting for site and symptoms. Main outcome measures: COVID‐19 antibody status and symptoms of COVID‐19 among pregnant women. Results: Among 19 218 non‐vaccinated pregnant women who were evaluated, 14.1% of antibody‐positive women had one or more symptoms compared with 13.4% in antibody‐negative women. Overall, 85.3% of antibody‐positive women reported no COVID‐19 symptoms during the present pregnancy. Reported fever was significantly associated with antibody status (relative risk [RR] 1.10, 95% CI 1.03–11.18; P = 0.008). A multiple variable model adjusting for site and all eight symptoms during pregnancy showed similar results (RR 1.13, 95% CI 1.04–1.23; P = 0.012). None of the other symptoms was significantly related to antibody positivity. Conclusions: In a population‐based cohort in LMICs, unvaccinated pregnant women who were antibody‐positive had slightly more symptoms during their pregnancy and a small but significantly greater increase in fever. However, for prevalence studies, evaluating COVID‐19‐related symptoms does not appear to be useful in differentiating pregnant women who have had a COVID‐19 infection. [ABSTRACT FROM AUTHOR]

This article, published in the BJOG: An International Journal of Obstetrics & Gynaecology, discusses COVID-19 vaccination rates and vaccine hesitancy among pregnant women in seven low- and middle-income countries. The study collected data from February 2021 to May 2023 and found that vaccination rates increased over time, with the highest rates in India and Bangladesh. Vaccine hesitancy decreased, and concerns about safety and side effects were associated with refusal. The authors emphasize the importance of education and positive messaging to increase vaccination rates among pregnant women. [Extracted from the article]

Objectives: We sought to determine the knowledge, attitudes and practices of pregnant women regarding COVID‐19 vaccination in pregnancy in seven low‐ and middle‐income countries (LMIC). Design: Prospective, observational, population‐based study. Settings Study areas in seven LMICs: Bangladesh, India, Pakistan, Guatemala, Democratic Republic of the Congo (DRC), Kenya and Zambia. Population: Pregnant women in an ongoing registry. Methods: COVID‐19 vaccine questionnaires were administered to pregnant women in the Global Network's Maternal Newborn Health Registry from February 2021 through November 2021 in face‐to‐face interviews. Main outcome measures: Knowledge, attitude and practice regarding vaccination during pregnancy; vaccination status. Results: No women were vaccinated except for small proportions in India (12.9%) and Guatemala (5.5%). Overall, nearly half the women believed the COVID‐19 vaccine is very/somewhat effective and a similar proportion believed that the COVID‐19 vaccine is safe for pregnant women. With availability of vaccines, about 56.7% said they would get the vaccine and a 34.8% would refuse. Of those who would not get vaccinated, safety, fear of adverse effects, and lack of trust predicted vaccine refusal. Those with lower educational status were less willing to be vaccinated. Family members and health professionals were the most trusted source of information for vaccination. Conclusions: This COVID‐19 vaccine survey in seven LMICs found that knowledge about the effectiveness and safety of the vaccine was generally low but varied. Concerns about vaccine safety and effectiveness among pregnant women is an important target for educational efforts to increase vaccination rates. The COVID‐19 vaccine survey in seven LMIC indicates that the knowledge of pregnant women about the effectiveness and safety of the vaccine was generally low and a third of the women did not plan to be vaccinated. [ABSTRACT FROM AUTHOR]

Objective: On a population basis, we assessed medical care for pregnant women in specific geographic regions of six countries before and during the first year of the COVID-19 pandemic in relationship to pregnancy outcomes.Design: Prospective, population-based study.Setting: Communities in Kenya, Zambia, the Democratic Republic of the Congo, Pakistan, India, and Guatemala.Population: Pregnant women enrolled in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry METHODS: Pregnancy/delivery care services and pregnancy outcomes in the pre-COVID-19 time-period (March 2019-February 2020) were compared to the COVID-19 time-period (March 2020-February 2021).Main Outcome Measures: Stillbirth, neonatal mortality, preterm birth, low birth weight, maternal mortality RESULTS: Across all sites, a small but statistically significant increase in home births occurred between the pre-COVID and COVID periods. (18.9% vs 20.3%, aRR 1.12 95% CI 1.05, 1.19). Also, a small but significant decrease in the mean number of antenatal care visits (4.1 - 4.0, p= <0.0001) was seen during the COVID-19 period. Of outcomes evaluated, overall, a small but significant decrease in low-birthweight in the COVID-19 period occurred (15.7% vs 14.6%, aRR 0.94 (0.89, 0.99), but we did not observe any significant differences in other outcomes. There was no change observed in maternal mortality or antenatal haemorrhage overall or at any of the sites.Conclusions: Small but significant increases in home births and decreases in the ANC services were observed during the initial COVID-19 period; however, there was not an increase in the stillbirth, neonatal mortality, maternal mortality, low birth weight or preterm birth rates during the COVID-19 period as compared to the prior year. Further research should help elucidate the relationship between access to and use of pregnancy-related medical services and birth outcomes over an extended period. [ABSTRACT FROM AUTHOR]

Pregnant women in 7 low and middle income sites often had incomplete knowledge related to COVID‐19 and practices to prevent COVID‐19 during pregnancy varied. [ABSTRACT FROM AUTHOR]

We thank Drs Sookaromdee and Wiwanitkit for their interest in our paper describing COVID-19 vaccine knowledge, attitude and practices among pregnant women in the eight sites of the Global Network for Women's and Children's Health, and especially for their focus on discrepancies in vaccination rates and vaccine hesitancy among pregnant women.1,2 Several health data systems track population vaccination rates by country.3 The discrepancy in vaccination rates between sub-Saharan Africa and the rest of the world is stark. Sookaromdee and Wiwanitkit emphasize the importance of appropriate COVID-19 education as a method to increase vaccination rates. Variability in COVID-19 vaccination rates in pregnant women: Vaccine hesitancy or supply limitations?. [Extracted from the article]

Objective: To determine the relation of COVID-19 symptoms to COVID-19 antibody positivity among unvaccinated pregnant women in low- and middle-income countries (LMIC)., Design: COVID-19 infection status measured by antibody positivity at delivery was compared with the symptoms of COVID-19 in the current pregnancy in a prospective, observational cohort study in seven LMICs., Setting: The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR), a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (Belagavi and Nagpur sites) and Guatemala., Population: Pregnant women enrolled in the ongoing pregnancy registry at study sites., Methods: Data on COVID-19 symptoms during the current pregnancy were collected by trained staff between October 2020 and June 2022. COVID-19 antibody testing was performed on samples collected at delivery. The relation between COVID-19 antibody positivity and symptoms was assessed using generalised linear models with a binomial distribution adjusting for site and symptoms., Main Outcome Measures: COVID-19 antibody status and symptoms of COVID-19 among pregnant women., Results: Among 19 218 non-vaccinated pregnant women who were evaluated, 14.1% of antibody-positive women had one or more symptoms compared with 13.4% in antibody-negative women. Overall, 85.3% of antibody-positive women reported no COVID-19 symptoms during the present pregnancy. Reported fever was significantly associated with antibody status (relative risk [RR] 1.10, 95% CI 1.03-11.18; P = 0.008). A multiple variable model adjusting for site and all eight symptoms during pregnancy showed similar results (RR 1.13, 95% CI 1.04-1.23; P = 0.012). None of the other symptoms was significantly related to antibody positivity., Conclusions: In a population-based cohort in LMICs, unvaccinated pregnant women who were antibody-positive had slightly more symptoms during their pregnancy and a small but significantly greater increase in fever. However, for prevalence studies, evaluating COVID-19-related symptoms does not appear to be useful in differentiating pregnant women who have had a COVID-19 infection., (© 2023 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)