Public-private mix (PPM) DOTS is feasible in the cities of Pakistan. However, the cost, time and effort required to establish the programme is higher than in many other developing countries.

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.

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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.

Background According to global estimates for 2017, nearly 295,000 maternal deaths occurred worldwide. Thus, approximately 810 women die every day due to pregnancy-related complications. This burden of maternal deaths in LMICs is primarily due to poor healthcare service utilization, as indicated by relatively low rates of institutional deliveries and skilled-birth attendance (SBA). We conducted this study with an aim to assess the factors associated with home delivery and its subsequent effect on the pregnancy outcome in rural Sindh, Pakistan. Methods Data for this study were taken from The Global Network’s Maternal Newborn Health Registry (MNHR), which is a prospective, population-based observational cohort study. Registry data for 2018–2019 for District Thatta, Pakistan was retrieved for the analysis. Multivariable logistic regression models were used to determine the effect of each independent variable on the place of delivery by including all predictors and covariates. Results of the regression analyses are presented with crude odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Results A total of 4649 women were included in the study, of these, 1286 (27.7%) women had delivered at home. Of those who delivered at home, a larger proportion was illiterate (90%), had a BMI of less than 18.5 kg/m2 (26.0%), had parity of 3 or more (48.1%), and had a history of pregnancy loss as compared to women who had institutional delivery. In addition, two-thirds of women (63.4%) who had delivered at home had less than 4 ANC visits, whereas 15.6% did not receive any ANC. On multivariable logistic regression we found that home delivery was significantly associated with being illiterate (aOR = 1.60; [95% CI: 1.34, 2.04]), having high parity (aOR = 1.91; [95% CI: 1.58, 2.32]), and no ANC visit (aOR = 14.8; [95% CI: 10.2, 21.5]). Conclusions More than a quarter of our study sample women delivered at home. These women were illiterate, multiparous, and did not receive antenatal care during pregnancy. It is essential to conduct extensive educational interventions for the women and their family members regarding the potential benefits of delivering in a safe and skilled environment. Moreover, the provision of comprehensive and quality antenatal care should be ensured as it improves the mothers' health-seeking behavior and helps them make informed decisions about their health and well-being.

ObjectiveTo determine the relation of COVID‐19 symptoms to COVID‐19 antibody positivity among unvaccinated pregnant women in low‐ and middle‐income countries (LMIC).DesignCOVID‐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.SettingThe 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.PopulationPregnant women enrolled in the ongoing pregnancy registry at study sites.MethodsData 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 measuresCOVID‐19 antibody status and symptoms of COVID‐19 among pregnant women.ResultsAmong 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.ConclusionsIn 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.