Case fatality rate and determinants of maternal death among pregnant women with SARS-CoV-2 infection: A population-based cohort study in Bahia, Brazil

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OBJECTIVES: To estimate the case fatality rate (CFR) of SARS-CoV-2 infection among pregnant women in Bahia, Brazil, and to identify individual- and community-level factors associated with maternal death. METHODS: We conducted a population-based retrospective cohort study including all women at ≥20 weeks of gestation with laboratory-confirmed SARS-CoV-2 infection between 2020 and 2022. CFRs were estimated overall and stratified by sociodemographic and clinical characteristics. Multilevel logistic regression models were used to identify individual- and contextual-level determinants of maternal mortality. RESULTS: The overall CFR was 2.2%. Higher fatality rates were observed among older women, those with lower educational attainment, fewer prenatal visits, cesarean delivery, and unvaccinated status. Independent predictors of death included multiparity, fewer prenatal visits, cesarean section, infection during the third trimester, limited availability of obstetric beds, and higher regional maternal mortality ratios. Study limitations include the use of secondary surveillance data and lack of information on comorbidities and behavioral factors. CONCLUSION: Social, clinical, and healthcare access factors significantly influenced SARS-CoV-2-related maternal deaths in Bahia. Preventing maternal deaths in future respiratory epidemics will require expanding vaccination coverage, ensuring comprehensive prenatal and obstetric care, and promoting evidence-based decisions regarding delivery mode, particularly in regions historically burdened by high maternal mortality.