The impact of the COVID-19 infections on pregnancy outcomes in Indonesia

Pregnant women face higher COVID-19 case fatality rates (CFR) alongside increased risks of adverse maternal and perinatal outcomes, yet evidence from Indonesia remains limited. This study assessed the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on pregnancy outcomes in the Indonesian population. A retrospective cohort study was conducted in eight selected tertiary and secondary COVID-19 referral hospitals across four provinces with high maternal COVID-19 mortality in Indonesia (East Java, Central Java, West Java, and Special Region of Yogyakarta). Pregnant women hospitalised between March 1, 2020, and December 31, 2022, who underwent SARS-CoV-2 testing during hospitalisation and completed their pregnancy were included, comprising both laboratory-confirmed SARS-CoV-2–positive and –negative participants. Logistic regression analyses were performed to estimate the associations between COVID-19 status, demographic and clinical determinants, including vaccination, and key maternal and perinatal outcomes. A cohort of 4,945 pregnant women were recruited, and 2,522 (51%) tested positive for COVID-19. CFR of pregnant women with COVID-19 was 4.04% (102/2,525), notably higher than those without COVID-19 (0.73%, 17/2,420). Maternal death was significantly higher in COVID-19–positive with moderate-to-severe infection compared to the COVID-19–negative participants (aOR 11.29, 95% CI: 4.82–26.46) after adjusting clinical and socio-demographic variables. Subgroup analysis among confirmed COVID-19 participants showed higher mortality in moderate-to-severe COVID-19 compared to the asymptomatic-mild group (aOR 25.79, 95% CI: 4.48-148.49). The predictors of COVID-19 severity during pregnancy included advanced pregnant women age (either being 20–35 years [aOR 3.88, 95% CI: 1.35–11.14] or 35 years or above [aOR 3.46, 95% CI: 1.12–10.82]), infections occurring during the Beta wave (aOR 1.85, 95% CI: 1.04–3.30), recurrent infections (aOR 2.33, 95% CI: 1.21–4.50), elevated levels of procalcitonin (aOR 1.046, 95% CI: 1.011–1.082) and D-Dimer (aOR 1.008, 95% CI: 1.002–1.014), with bilateral pneumonia as the most prominent predictor (aOR 4.82, 95% CI: 3.07–7.56). Conversely, vaccination against COVID-19, irrespective of the received doses, emerged as a protective factor (aOR 0.45, 95% CI: 0.22–0.93) against severe outcomes of COVID-19. Severe COVID-19 infections during pregnancy are associated with elevated maternal mortality rates. Vaccination against COVID-19 exhibited protective effects, highlighting the importance of vaccinating pregnant women as a crucial preventive measure of severe COVID-19 outcomes and fatalities.