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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.

Tweetable abstract 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.

Objectives To determine COVID‐19 antibody positivity rates over time and relationships to pregnancy outcomes in low‐ and middle‐income countries (LMICs). Design With COVID‐19 antibody positivity at delivery as the exposure, we performed a prospective, observational cohort study in seven LMICs during the early COVID‐19 pandemic. 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 (two sites), and Guatemala. Population Pregnant women enrolled in an ongoing pregnancy registry at study sites. Methods From October 2020 to October 2021, standardised COVID‐19 antibody testing was performed at delivery among women enrolled in MNHR. Trained staff masked to COVID‐19 status obtained pregnancy outcomes, which were then compared with COVID‐19 antibody results. Main Outcome Measures Antibody status, stillbirth, neonatal mortality, maternal mortality and morbidity. Results At delivery, 26.0% of women were COVID‐19 antibody positive. Positivity increased over the four time periods across all sites: 13.8%, 15.4%, 21.0% and 40.9%. In the final period, positivity rates were: DRC 27.0%, Kenya 33.1%, Pakistan 32.8%, Guatemala 37.0%, Zambia 37.8%, Bangladesh 47.2%, Nagpur, India 57.4% and Belagavi, India 62.4%. Adjusting for site and maternal characteristics, stillbirth, neonatal mortality, low birthweight and preterm birth were not significantly associated with COVID‐19. The adjusted relative risk (aRR) for stillbirth was 1.27 (95% CI 0.95–1.69). Postpartum haemorrhage was associated with antibody positivity (aRR 1.44; 95% CI 1.01–2.07). Conclusions In pregnant populations in LMICs, COVID‐19 antibody positivity has increased. However, most adverse pregnancy outcomes were not significantly associated with antibody positivity.

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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.

IntroductionExisting risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2–59 months at risk of hospitalised pneumonia-related mortality across various settings.MethodsWe used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool.ResultsA total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84).ConclusionsThe PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality.