This research is pioneer in the analysis of the socio-demographic profile of PWWE in the Northeast region of Brazil. Regarding the characteristics of these women, the results showed that most of them lived rural areas, were illiterate, had cesarean delivery at childbirth, and had at least one abortion. Considering both groups, PWWE and PWNE, we observed that they were mostly brown-colored, single, housewives, and multiparous.
The prevalence of PWWE (0.49%) between the years 2008 and 2020 in high-risk pregnancy referral centers of Alagoas state is in agreement with other authors, who described a prevalence of 0.4–0.8% in this population . Our results showed that more than half of PWWE live in the interior of the state, where only 26.36% of the Alagoas population resides  and that they are more likely to have epilepsy than pregnant women who were born in the capital. Epilepsy is a global disease with uneven distribution. Approximately 80% of affected individuals reside in low- and middle income countries. The incidence and prevalence of epilepsy in low-income populations are higher than those in the rest of the world. The average lifetime prevalence of epilepsy in developed countries is 5.8 per 1,000, while in rural areas of developing countries it is 15.4 per 1,000 . The severe precariousness of resources in the interior of the Alagoas state may be the reason of the higher percentage of PWWE found in this location and may also explain the younger age at which WWE become pregnant compared to other countries. In contrast to this study, one study conducted in the city of Toledo, Paraná State, which included both men and WWE, found that 83.8% of them were from urban areas, where 77.38% of the population is concentrated .
This study found no age difference between the PWWE and PWNE. Our sample was also younger than samples of PWWE from studies conducted in other countries, where the average age ranged between 27.4 and 30.4 years old [7–13–29]. Between 2012 and 2016, the Brazilian Northeast region was identified as the third with the highest number of hospitalizations of WWE in this reproductive group (n = 8,245, 19.53%). Among them, the most frequent were women between 20 and 29 years old (n = 1,944, 20.32%) .
Regarding race, the majority of pregnant women with and without epilepsy were of brown ethnicity (88.6%), which is in line with previous work conducted in the Brazilian Northeast region, which showed that 49.22% of hospitalized WWE were brown-colored . The population in Alagoas between 2012 and 2019 showed that 44.87% were brown, favoring this high rate among pregnant women .
Concerning the type of delivery, PWWE were approximately 20 times more likely to have a cesarean section than PWNE. This study conducted in the United States also verified these results, albeit with a smaller probability . Consistent with our results, research studies performed in the US and China observed that PWWE were more likely than PWNE to have cesarean delivery (40.5% vs. 33.1% and 85.3% vs. 50.3%, respectively) [10–31]. Previous studies have concluded that PWWE have an increased risk of preterm delivery, cesarean section, and labor induction during childbirth [11–25–26–27–31]. Other authors have described that factors such as multiparity, age, and probable complications in childbirth contribute to cesarean section, in addition to the need for tubal ligation . In contrast to our results, European studies found lower cesarean delivery rates in PWWE (18.8% vs. 34%) [9–26]. Additionally, some studies reported a higher incidence of vaginal deliveries [33–34]. Brazilians seem to have a culture concerning their preference for cesarean section delivery, where social, institutional, financial, and obstetric practice factors influence their choice . In agreement with this information, the cesarean rate in the state of Alagoas was 52.3% in 2019 , which is higher than that observed in European studies, but smaller than that observed in our patients with epilepsy.
Another observation was between PWWE and the occurrence of spontaneous abortion, which was significantly different from that observed among PWNE. The values of miscarriages in epileptic women in our research and in those of other studies were (21.9%), (21.4%) and (8.5%), respectively [24–27–28]. An American study also showed consonant results (OR adjusted, 1.27 ; 95% CI, 1.17–1,38) . The Australian Register between 1999 to end 2014 and a meta-analysis of 39 studies from 1990 to 2015, comprising 2,837,325 pregnancies in low- and high-income countries, compared PWWE versus PWNE to look at between 1999 to the end of 2014 the association between epilepsy in pregnancy as well as exposure to AEDs and several maternal and fetal outcomes. It concluded that PWWE is associated with adverse pregnancy outcomes, such as miscarriage (OR 1.54; 95% CI 1.02–2.32; 67%) (OR = 1,45; 95% CI1,12 − 1,87; 21,4% ) [23–24].
In this study, multiparity was evident in both PWWE and PWNE (58–60%), which is in contrast with other studies. A recent Brazilian study in Toledo city, Paraná, showed multiparity rates of 15,4% among WWE . European studies found rates between 20.8% and 36% for multiparity [7–26], while a study performed in the United States observed very low rates among PWWE and PWNE (1,7%–1,8%) . In contrast with our study with our study the population-based retrospective cohort in Sweden, a higher number of primiparous patients were found .
Considering the findings of our study and the socio-demographic profile of PWE in low- and middle-income countries, it would be expected to observe lower levels of education and higher levels of unemployment among PWWE from the Alagoas state than in other regions, characterized by strong economic resources. Regarding employment, no association was observed between PWWE and unemployment; however, a similar and high number of PWWEs and PWNEs reported being homemakers, which may be in part related to the unemployment.
Regarding education, we verified that PWNEs were significantly more literate than PWWE, and an association between these groups of women with illiteracy was found. Multiparity, low education, and unemployment may be highly related. According to studies, 50% of girls in Teresina, a city in northeastern Brazil, stopped their studies during their first pregnancy , which may have a serious influence on the probability of having a job and contribute to the unemployment rate. The same hypothesis may be applied to our population for explaining the observed results. In addition, the Brazilian National Survey by Samples by Household of 2015 (PNAD) has shown severe per capita inequality in the country and the lowest average income of the northeastern population as well as in other populations . To assist the underprivileged population, the Brazilian government through social inclusion programs, such as the Family Allowance Program, performs monthly income transfers to poor and extremely poor families . Such programs have assisted and addressed the basic needs of these populations; however, they may have also contributed to the high number of women multiparity rates WWE .
According to previous studies, the socio-demographic profile of PWE living in low- and middle-income countries is characterized by low education and unemployment . However, such findings are not exclusive to less-developed countries, since a study involving seven European countries reported low levels of education among PWE who attained elementary or secondary levels. In addition, 18% of them were unemployed . Considering the national panorama, a study from Paraná (South Brazilian region) found that the majority of PWE had incomplete primary education (59.6%), while only 14.0% completed primary school , which is in line with the results of our work. A contrast may be observed between the results observed in Santa Catarina , another South Brazilian region, where, despite the small sample, the authors observed that 30.2% (n = 13) of PWE were illiterate, while in our PWWE sample, 7% (n = 15) had no schooling. In line with that result, the present study revealed that being a homemaker was the main occupation among PWWE (76.9%), while only 8.2% were students, thus confirming the low levels of education and high levels of unemployment. However, we also found low levels of education (11.8%) and unemployment (72.2%) in pregnant women without epilepsy, perhaps because the high-risk pregnancy centers where the study sample was recruited are public institutions.
Regarding the composition of the family nucleus, our results did not show a significant difference in marital status between PWWE and PWNE, and indicated that most PWWE were single (47.3%), while most PWNE had stable union (43.8%). Our study found no association between PWWE and marital status. Previous studies conducted in European countries and in the southern Brazilian region described the stigma of marriage in PWE, showing that this population is more likely to be single or divorced [38–39], while others described them as being mostly single (46.5%) and married or in a stable relationship (44.2%) .