Obstetric interventions and pregnancy outcomes during the COVID-19 pandemic in England: A nationwide cohort study

Abstract

Background The COVID-19 pandemic has disrupted maternity services worldwide and imposed restrictions on societal behaviours. This national study aimed to compare obstetric intervention and pregnancy outcome rates in England during the pandemic and corresponding pre-pandemic calendar periods, and to assess whether differences in these rates varied according to ethnic and socioeconomic background. Methods and findings We conducted a national study of singleton births in English National Health Service hospitals. We compared births during the COVID-19 pandemic period (23 March 2020 to 22 February 2021) with births during the corresponding calendar period 1 year earlier. The Hospital Episode Statistics database provided administrative hospital data about maternal characteristics, obstetric inventions (induction of labour, elective or emergency cesarean section, and instrumental birth), and outcomes (stillbirth, preterm birth, small for gestational age [SGA; birthweight < 10th centile], prolonged maternal length of stay (≥3 days), and maternal 42-day readmission). Multi-level logistic regression models were used to compare intervention and outcome rates between the corresponding pre-pandemic and pandemic calendar periods and to test for interactions between pandemic period and ethnic and socioeconomic background. All models were adjusted for maternal characteristics including age, obstetric history, comorbidities, and COVID-19 status at birth. The study included 948,020 singleton births (maternal characteristics: median age 30 years, 41.6% primiparous, 8.3% with gestational diabetes, 2.4% with preeclampsia, and 1.6% with pre-existing diabetes or hypertension); 451,727 births occurred during the defined pandemic period. Maternal characteristics were similar in the pre-pandemic and pandemic periods. Compared to the pre-pandemic period, stillbirth rates remained similar (0.36% pandemic versus 0.37% pre-pandemic, p = 0.16). Preterm birth and SGA birth rates were slightly lower during the pandemic (6.0% versus 6.1% for preterm births, adjusted odds ratio [aOR] 0.96, 95% CI 0.94–0.97; 5.6% versus 5.8% for SGA births, aOR 0.95, 95% CI 0.93–0.96; both p < 0.001). Slightly higher rates of obstetric intervention were observed during the pandemic (40.4% versus 39.1% for induction of labour, aOR 1.04, 95% CI 1.03–1.05; 13.9% versus 12.9% for elective cesarean section, aOR 1.13, 95% CI 1.11–1.14; 18.4% versus 17.0% for emergency cesarean section, aOR 1.07, 95% CI 1.06–1.08; all p < 0.001). Lower rates of prolonged maternal length of stay (16.7% versus 20.2%, aOR 0.77, 95% CI 0.76–0.78, p < 0.001) and maternal readmission (3.0% versus 3.3%, aOR 0.88, 95% CI 0.86–0.90, p < 0.001) were observed during the pandemic period. There was some evidence that differences in the rates of preterm birth, emergency cesarean section, and unassisted vaginal birth varied according to the mother’s ethnic background but not according to her socioeconomic background. A key limitation is that multiple comparisons were made, increasing the chance of false-positive results. Conclusions In this study, we found very small decreases in preterm birth and SGA birth rates and very small increases in induction of labour and elective and emergency cesarean section during the COVID-19 pandemic, with some evidence of a slightly different pattern of results in women from ethnic minority backgrounds. These changes in obstetric intervention rates and pregnancy outcomes may be linked to women’s behaviour, environmental exposure, changes in maternity practice, or reduced staffing levels.

Impact of the COVID-19 pandemic on midwifery-led service provision in the United Kingdom in 2020-21: Findings of three national surveys

“…There is some evidence that overall rates of perinatal mental health disorders increased internationally during the pandemic, including anxiety and depression, with links to the modification of maternity services ( Fan et al, 2021 ). We were unable to assess any impact of the changes we observed on outcomes for women and babies, but in terms of interventions and outcomes, in England one study has reported evidence of increased rates of obstetric intervention, including induction and Caesarean section, but little evidence of impact on adverse outcomes ( Gurol-Urganci et al, 2022 ). The impact on maternity staff was also beyond the scope of the surveys reported here, but is important to consider ( Horsch et al, 2020 ).…”

COVID-19 pandemic impact on preterm birth and stillbirth rates associated with socioeconomic disparities: A quasi-experimental study

“…In addition, the effect modification by SES was not assessed in the aforementioned studies. [19][20][21][22] Within the published literature, single-center 45,51,[53][54][55] and national [56][57][58][59][60] studies have reported conflicting evidence in relation to perinatal outcomes during the COVID-19 pandemic. In a metaanalysis, Yang et al examined the influence of COVID-19 restrictions on maternal and neonatal outcomes.…”

Viral pulmonary infection in pregnancy – Including COVID-19, SARS, influenza A, and varicella

“…( 15 , 16 ) Whilst the figures differ between various studies, maternal COVID-19 may be associated with increased risk of preeclampsia, delivery by caesarean section, preterm birth and stillbirth. ( 17 , 18 , 19 , 20 , 21 ) There was a stronger association with the latter during the period when the Delta (SARS-CoV-2 B.1.617.2) variant was predominant compared to the pre-Delta period. ( 22 ) The caveat is that not all mothers were tested for infection and many individuals were asymptomatic.…”

“…There is limited literature to suggest that maternal COVID-19 has additional adverse effects in neonates apart from those related to prematurity. ( 20 , 21 , 22 , 23 )…”