Background Early reports of COVID‐19 in pregnancy described management by caesarean, strict isolation of the neonate and formula feeding. Is this practice justified? Objective To estimate the risk of the neonate becoming infected with SARS‐CoV‐2 by mode of delivery, type of infant feeding and mother‐infant interaction. Search strategy Two biomedical databases were searched between September 2019 and June 2020. Selection criteria Case reports or case series of pregnant women with confirmed COVID‐19, where neonatal outcomes were reported. Data collection and analysis Data were extracted on mode of delivery, infant infection status, infant feeding and mother–infant interaction. For reported infant infection, a critical analysis was performed to evaluate the likelihood of vertical transmission. Main results Forty nine studies included information on mode of delivery and infant infection status for 655 women and 666 neonates. In all, 28/666 (4%) tested positive postnatally. Of babies born vaginally, 8/292 (2.7%) tested positivecompared with 20/374 (5.3%) born by Caesarean. Information on feeding and baby separation were often missing, but of reported breastfed babies 7/148 (4.7%) tested positive compared with 3/56 (5.3%) for reported formula fed ones. Of babies reported as nursed with their mother 4/107 (3.7%) tested positive, compared with 6/46 (13%) for those who were reported as isolated. Conclusions Neonatal COVID‐19 infection is uncommon, rarely symptomatic, and the rate of infection is no greater when the baby is born vaginally, breastfed or remains with the mother. Tweetable abstract Risk of neonatal infection with COVID‐19 by delivery route, infant feeding and mother‐baby interaction.

A note on versions:The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher's version. Please see the repository url above for details on accessing the published version and note that access may require a subscription.For more information, please contact eprints@nottingham.ac.ukThe new england journal of medicine n engl j med 374;9 nejm.org

A note on versions:The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher's version. Please see the repository url above for details on accessing the published version and note that access may require a subscription.For more information, please contact eprints@nottingham.ac.ukThe new england journal of medicine n engl j med 374;9 nejm.org

A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.

No abstract

criterion. However, we acknowledged in the paper that other clinical, health system-related and sociodemographic issues could have been considered, but were beyond the scope of our study. We sought to make our methodology transparent, recognising that others might consider different criteria to define stillbirth preventability. For the paper, we describe the clinical conditions, rather than the technical ICD-10 designations, to make the results more understandable to clinicians reading the paper.Despite these nuances, we are confident thatthedatasupportourmainconclusions that the majority of stillbirths occurring in many low-resource settings are preventable withgenerally availableresources, and the most common medical conditions associated with stillbirth in these settings include a small-for-gestational-age fetus, pre-eclampsia, placental abruption and deaths occurring after admission to the hospital. Focusing on improving obstetric care for these conditions should result in a substantial reduction in stillbirths in many low-resource settings.

We agree there are many weaknesses in the data we reviewed. Dr Xue has identified one. Others are the incomplete reporting of infant feeding and mother-child interactions, and the frequent lack of infant testing to confirm or refute the possibility of vertical transmission of COVID-19. Finally, although we simply provided summary totals, it would be statistically preferable to combine series using the Mantel-Haenszel method and calculate a relative risk. We judged that doing this in light of the uncertainties around the data which Dr Xue has identified, might give a spurious precision to our results. As he says, more work is needed. For now we think it remains reasonable to not regard COVID-19 in itself, as an indication for Caesarean, artificial feeding or separation, in the mother and baby's interest.

This a preprint and has not been peer reviewed. Data may be preliminary.