Pandemic linked to substantially worse pregnancy outcomes worldwide

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Pregnancy outcomes for mothers and babies have worsened during the COVID-19 pandemic, with stillbirth and maternal mortality rates increasing by approximately one-third during the pandemic, according to a review of data from 40 studies representing 17 countries, in The Lancet Global Health.

Pregnancy outcomes for mothers and babies have worsened during the COVID-19 pandemic, according to a review of data from 40 studies representing 17 countries, The findings varied by country, but analysis of pooled data showed stillbirth and maternal mortality rates increased by approximately one-third during the pandemic compared to life before COVID-19 took hold.

The study, led by St George’s University of London, found that mental health outcomes also worsened during the pandemic. Of the 10 studies included in the analysis, that reported on maternal mental health, six reported an increase in postnatal depression, maternal anxiety, or both.

Overall, outcomes were worse in low- and middle-income countries as compared to high-income countries and the researchers say immediate action is required to preserve safe maternity care worldwide, especially during the global emergency.

Although the study did not analyse the direct impact of COVID-19 infection during pregnancy, it provides the first global assessment of the collateral impact of the pandemic on antenatal, birth, and postnatal outcomes.

Professor Asma Khalil, lead author of the study from St George’s, said: “The COVID-19 pandemic has had a profound impact on healthcare systems around the world. Disruption to services, nationwide lockdowns, and fear of attending health care facilities mean that the adverse effects of COVID-19 are expected to have health consequences that extend beyond the deaths and disease caused by the virus itself.

“It is clear from our study and others that the disruption caused by the pandemic has led to the avoidable deaths of both mothers and babies, especially in low- and middle-income countries. We urge policymakers and health care leaders to prioritise safe, accessible, and equitable maternity care within the strategic response to the pandemic and aftermath, to reduce adverse pregnancy outcomes worldwide.”

Studies from individual countries have suggested that the pandemic has affected rates of stillbirth and pre-term birth, potentially as a result in a reduction of healthcare-seeking behaviour for fear of infection, as well as reduced provision of maternity services.

In this latest study, the researchers reviewed data from 40 studies that were published between 1 January 2020 and 8 January 2021, representing 17 countries and with data from more than 6 million pregnancies. All of the studies compared pregnancy outcomes during and before the pandemic.

The review did not find any difference in overall rates of pre-term birth before and during the pandemic. However, pooled data from studies from high-income countries suggest that, in this setting, the odds of preterm birth were reduced by almost 10% during the pandemic. The authors say the reduction appears to be driven by a drop in spontaneous pre-term birth, rather than those requiring medically indicated early induction of labour or caesarean section, which may be increased. They say this means it is more likely that changes in health care delivery and population behaviours are contributing factors, which may bring valuable lessons for understanding the mechanisms underlying preterm birth.

The researchers found the variation in outcomes reported between different studies included in the paper may be partially explained by inefficiencies in health care systems in the countries studied. However, differences in pandemic mitigation responses between countries did not seem to affect the findings. The researchers say this suggests the increase in adverse pregnancy outcomes may be driven by pressures on health care systems caused by COVID-19 itself, rather than measures aimed at limiting the spread of the virus, such as lockdowns.

Dr Erkan Kalafat, a co-author of the study from Koc University-Turkey, said: “We have an unprecedented opportunity to learn from the experiences of the COVID-19 pandemic to plan for a future of inclusive and equitable maternity care worldwide. One such learning opportunity will be to investigate the mechanisms underlying the apparent reduction in pre-term births observed in high-income settings during the pandemic, with a view to identifying new preventative interventions that could potentially benefit all women worldwide.”

The authors note several limitations to their findings. Notably, the studies included in their analysis varied in the way pregnancy outcomes were defined and measured, which makes it difficult to compare results between studies. There were fewer studies from low- and middle-income settings, which may be concerning as the analysis shows substantial variation in outcomes between high- and low-income settings. The authors also note that they cannot exclude the risk of publication bias against studies reporting negative findings, although they did not find any evidence of bias when they tested for this.

 

Study details
Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis

Barbara Chmielewska, Imogen Barratt, Rosemary Townsend, Erkan Kalafat, Jan van der Meulen, Ipek Gurol-Urganci, Pat O’Brien, Edward Morris, Tim Draycott, Shakila Thangaratinam, Kirsty Le Doare, Shamez Ladhani, Peter von Dadelszen, Laura Magee, Asma Khalil

Published in The Lancet Global Health on 31 March 2021

Abstract
Background
The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has been undertaken. We aimed to assess the collective evidence on the effects on maternal, fetal, and neonatal outcomes of the pandemic.
Methods
We did a systematic review and meta-analysis of studies on the effects of the pandemic on maternal, fetal, and neonatal outcomes. We searched MEDLINE and Embase in accordance with PRISMA guidelines, from Jan 1, 2020, to Jan 8, 2021, for case-control studies, cohort studies, and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications, and intrapartum and neonatal outcomes before and during the pandemic. We also planned to record any additional maternal and offspring outcomes identified. Studies of solely SARS-CoV-2-infected pregnant individuals, as well as case reports, studies without comparison groups, narrative or systematic literature reviews, preprints, and studies reporting on overlapping populations were excluded. Quantitative meta-analysis was done for an outcome when more than one study presented relevant data. Random-effects estimate of the pooled odds ratio (OR) of each outcome were generated with use of the Mantel-Haenszel method. This review was registered with PROSPERO (CRD42020211753).
Findings
The search identified 3592 citations, of which 40 studies were included. We identified significant increases in stillbirth (pooled OR 1·28 [95% CI 1·07–1·54]; I2=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 [1·22–1·53; I2=0%, two studies [both from low-income and middle-income countries], 1 237 018 and 2 224 859 pregnancies) during versus before the pandemic. Preterm births before 37 weeks’ gestation were not significantly changed overall (0·94 [0·87–1·02]; I2=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 [0·84–0·99]; I2=63%; 12 studies, 159 987 and 635 118 pregnancies), where spontaneous preterm birth was also decreased (0·81 [0·67–0·97]; two studies, 4204 and 6818 pregnancies). Mean Edinburgh Postnatal Depression Scale scores were higher, indicating poorer mental health, during versus before the pandemic (pooled mean difference 0·42 [95% CI 0·02–0·81; three studies, 2330 and 6517 pregnancies). Surgically managed ectopic pregnancies were increased during the pandemic (OR 5·81 [2·16–15·6]; I2=26%; three studies, 37 and 272 pregnancies). No overall significant effects were identified for other outcomes included in the quantitative analysis: maternal gestational diabetes; hypertensive disorders of pregnancy; preterm birth before 34 weeks’, 32 weeks’, or 28 weeks’ gestation; iatrogenic preterm birth; labour induction; modes of delivery (spontaneous vaginal delivery, caesarean section, or instrumental delivery); post-partum haemorrhage; neonatal death; low birthweight (<2500 g); neonatal intensive care unit admission; or Apgar score less than 7 at 5 min.
Interpretation
Global maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression. Some outcomes show considerable disparity between high-resource and low-resource settings. There is an urgent need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises.
Funding
None.

 

The Lancet Global Health study (Open access)

 

See also MedicalBrief archives:

30% increase in maternal deaths in SA during first wave of COVID-19

Ethnic minorities in UK at up-to 4x higher mortality risk from COVID-19 — NHS data analysis

One stillbirth every 16 seconds, according to first ever joint UN estimates


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