Using Ministry of Health data, we assessed the odds ratios of preterm births in Brazil and its regions, before and during the pandemic. Our results indicated that, during the pandemic years of 2020 and 2021, preterm births have significantly increased as compared to pre-pandemic periods. This increase was not homogeneous across the country, and in certain regions, the pandemic has disrupted previous decline patterns or even accelerated the past trend of preterm deliveries growing; as observed in Northeastern, Southeastern, and Southern regions.
The ethnicity (indigenous women), low level of education, low number of antenatal care visits, and multiparity, extreme maternal ages, were associated with an increased risk of PTB. These data are similar to the findings of other population-based studies29,30.
Finding from individual studies and systematic review has suggested a global reduction in ANC clinic visits, maternity healthcare-seeking, and unscheduled care visits31; the same pattern was also observed in Brazil, where the quality of ANC was low (only 35.8% of the study participants had adequate), In addition, the risk of inadequate ANC was higher among pregnant women with black/brown skin colour and multiparous when compared to their contra part32. These factors potentially contributed to worsening pregnancy outcomes (including the preterm birth rate), even for married/cohabiting women.
During the COVID-19 access to the Internet and DICT (Digital Information and Communication Technologies) was heterogeneous within the Brazilian regions, and municipality, public and private health systems. And, to the best of our knowledge, data regarding the coverage of virtual or remote antenatal care were not available in the database [SINASC], and the ANC visits are not desegregated by the mode of consultation [remote vs in-person]), therefore, we have not considered this variable in our analysis.
The pandemic brought the attention of health experts and demographers that took the time to understand how COVID-19 could affect birth counts and, for instance, the chances of preterm deliveries in the country. Brazil is a country that suffered excessive mortality due to the COVID-19 pandemic2,33, as well as health facilities also were stressed by the high number of COVID-19 cases, and many services could not be properly provided by health units34. This exogenous sanitary problem might have also affected women’s antenatal care, especially among those that require more attention from public health services, i.e., mothers from low socioeconomic strata. Uncertainty and economic restrictions caused by the pandemic context may also play an important role in reproduction35, and compromise pregnancy and antenatal care in Brazil.
Among Brazilian regions, the Northeast requires special attention because this is a region marked by historically lower socioeconomic development that could be in turn associated with restricted health services access36,37, and the lack of strategy to mitigate the impact of the pandemic at different governmental levels3,33. Notwithstanding, the COVID-19 pandemic brought an enormous burden to Brazil’s Northern and Northeastern regions and revealed a sudden disruption of health care services38,39. These setbacks might in turn affect the preterm birth rate.
Our findings differ from other studies that indicated a reduction in preterm deliveries during the COVID-19 pandemic10,14,40,41,42,43,44. This could be partly explained by the measures applied to face the pandemic, which was uncoordinatedly implemented in Brazil36. Regional inequality in health services access and the slow degree of responsiveness of the Brazilian National Health System could have played a role in the unequal pandemic effects on preterm births across Brazilian regions. As previous studies indicate, less sub-national inequality is seen in high-income countries, recognized by strict lockdown policies and with developed health services according to the needs posed by the pandemic. Moreover, Brazil had more severe cases; one out of seven maternities had intensive unit beds, therefore resulting in the phase three delay—concerning receiving proper diagnosis and timely treatment1,45,46.
However, our findings suggested a different pattern of preterm birth rate in the Northern region. In the Northern region of Brazil, more than two–thirds of pregnant women did not attend antenatal care, and higher excess mortality (especially in Manaus city), which might have caused severe perinatal outcomes (miscarriage and fetal death)47,48.
Our study suggested an increased rate of caesarean delivery among preterm babies in 2020, and 2021 compared to previous periods. Therefore, we may speculate that the increased risk of PTB in 2020, and 2021 may be related to non-spontaneous (provider-initiated) preterm birth49,50.
It is important to mention that we concentrate our analysis and interpretations on the year’s effect only (comparison between control versus treatment, or pre-pandemic vs. pandemic period), and we do not get into detail about the other control variables, despite the models have shown important differences in preterm pregnancies among distinguished demographic and socioeconomic groups.
This study has some strengths and limitations. Our data covers the entire population of live births in Brazil, with information at the individual level20. The analysis of the different geographic regions allowed us to picture preterm birth developments in a country recognized for its regional inequality. The main limitation is related to the study design, which does not allow us to infer causality but only refers to the association between the pandemic and preterm births. We also did not assess the direct impact of COVID-19 on the occurrence of preterm births, and we considered the years 2020 and 2021 as risk factors that caused changes (from social, economic, and epidemiological order) brought by the pandemic onset. Likewise, our model did not include all variables associated with preterm birth, for example, human development index, availability and access to health services before and during the COVID-19 pandemic, cigarette smoking, BMI, maternal income, unemployment, maternal underlying medical conditions, and maternal infection (vector-borne diseases, urinary tract, genital, and respiratory infection [including COVID-19]). We did not assess the prevalence of fetal deaths and the abortion rates. But we recognize that these outcomes could have increased in situations of reduced access to adequate health services, impacting Brazil’s birth rates.
Although we did not see an expressive increase of preterm births, we still argue that the disruption of sexual and reproductive health services may have influenced pregnancy outcomes. Therefore, monitoring the preterm birth rate might be an essential strategy for assessing the quality of maternal and perinatal care and might help providers and policymakers to develop strategies to mitigate the problem.