PONE-D-21-29410Maternal mortality associated with COVID-19 in Brazil in 2020 and 2021: comparison with non-pregnant women and menPLOS ONE

Dear Dr. Gonçalves,

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Additional Editor Comments:

I congratulate you on your mesmerizing work. I have raised several concerns.

#1. Documenting that pregnant and postpartum women are at a higher risk of developing severe forms of COVID-19 isessential for prioritizing them in health care strategies.

Please cite references.

#2. Please explain plausible basic mechanism. (i.e., ACE2, SARS-CoV-2, pregnancy, molecular mechanism)

#3. The authors have to provide the policy implication regarding vaccination. Please see the landmark previos study.

Hwang J, Park SH, Lee SW, Lee SB, Lee MH, Jeong GH, Kim MS, Kim JY, Koyanagi A, Jacob L, Jung SY, Song J, Yon DK, Shin JI, Smith L. Predictors of mortality in thrombotic thrombocytopenia after adenoviral COVID-19 vaccination: the FAPIC score. Eur Heart J. 2021 Sep 21:ehab592. doi: 10.1093/eurheartj/ehab592. Epub ahead of print. PMID: 34545400; PMCID: PMC8500026.

#4. Limitation

Pregnancy patients was associted with depression [1] and low level physical activity [2], which may mediated the COVID-19 effect.

Please disscuss this in the limitation section and cite the top-tier papers below.

[1] Fond G, Nemani K, Etchecopar-Etchart D, Loundou A, Goff DC, Lee SW, Lancon C, Auquier P, Baumstarck K, Llorca PM, Yon DK, Boyer L. Association Between Mental Health Disorders and Mortality Among Patients With COVID-19 in 7 Countries: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021 Jul 27:e212274. doi: 10.1001/jamapsychiatry.2021.2274. Epub ahead of print. PMID: 34313711; PMCID: PMC8317055.

[2] Lee SW, Lee J, Moon SY, Jin HY, Yang JM, Ogino S, Song M, Hong SH, Abou Ghayda R, Kronbichler A, Koyanagi A, Jacob L, Dragioti E, Smith L, Giovannucci E, Lee IM, Lee DH, Lee KH, Shin YH, Kim SY, Kim MS, Won HH, Ekelund U, Shin JI, Yon DK. Physical activity and the risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 related mortality in South Korea: a nationwide cohort study. Br J Sports Med. 2021 Jul 22:bjsports-2021-104203. doi: 10.1136/bjsports-2021-104203. Epub ahead of print. PMID: 34301715; PMCID: PMC8300550.

Again, I congratulate your excellent paper.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: A very valuable article in my opinion, this article can be published as a scientific reference for many related research, the method of posing the problem was effective and linking the problem with the results was strong, the presentation of the information was consistent and understandable, the statistical method is strong and convincing, my only comment, I may need more introduction to understand the problem In the region of Brazil. I highly recommend this search

Reviewer #2: Good use of the routine data to answer important program question. Covid 19 pandemic has impacted public health globally. National level technical committees are faced with the questions to identify high risk groups in order to priortise public health interventions. Women with pregnancy were not included for covid vaccination due to lack of data and evidence. Later countries included this group based on the clinical evidence. Researchers in this manuscript have created evidence that pregnancy is a high risk group. This is important despite all its limitations.

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Reviewer #1: Yes: Issam J. A Abu Qeis

Reviewer #2: Yes: Dr Arun Kumar Aggarwal

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Maternal mortality associated with COVID-19 in Brazil in 2020 and 2021: comparison with non-pregnant women and men

PONE-D-21-29410R1

Dear Dr. Gonçalves,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Dong Keon Yon, MD, FACAAI

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

I congratulate you on your mesmerizing work.

Reviewers' comments: