Stillbirths and the COVID‐19 pandemic: Looking beyond SARS‐CoV‐2 infection

Abstract

Objective To study the impact of the COVID‐19 outbreak and subsequent lockdown on the incidence, associated causes, and modifiable factors of stillbirth. Methods An analytical case‐control study was performed comparing stillbirths from March to September 2020 (cases) and March to September 2019 (controls) in a tertiary care center in India. Modifiable factors were observed as level‐I, level‐II, and level‐III delays. Results A significant difference in the rate of stillbirths was found among cases (37.4/1000) and controls (29.9/1000) (P = 0.045). Abruption in normotensive women was significantly higher in cases compared to controls (P = 0.03). Modifiable factors or preventable causes were noted in 76.1% of cases and 59.6% of controls; the difference was highly significant (P < 0.001, relative risk [RR] 1.8). Level‐II delays or delays in reaching the hospital for delivery due to lack of transport were observed in 12.7% of cases compared to none in controls (P < 0.006, RR 47.7). Level‐III delays or delays in providing care at the facility were observed in 31.3% of cases and 11.5% of controls (P < 0.001, RR 2.7). Conclusion Although there was no difference in causes of stillbirth between cases and controls, level‐II and level‐III delays were significantly impacted by the pandemic, leading to a higher rate of preventable stillbirths in pregnant women not infected with COVID‐19.

COVID‐19 pandemic and population‐level pregnancy and neonatal outcomes: a living systematic review and meta‐analysis

“…Of 9123 records in the initial search, 37 articles were eligible for inclusion, of which 36 were used in the quantitative synthesis 2,6‐10,15‐44 (Figure 1). Eighteen full‐text reports were excluded: reasons for the exclusions are provided in Appendix .…”

“…49 Reports from low-resource settings described increased fear and stress among pregnant individuals, reluctance to access in-hospital care during a pandemic, financial or employment issues, childcare or home schooling challenges, maternity staff shortages, reduced access to in-hospital care, and perceived or actual reductions in available obstetric services, resulting in a significant reduction in institutional births. 8,9,17,30,31 Some reports noted a reduction in PTB and attributed this to a number of social and health behaviors associated with the pandemic, 2, 7 including decreased physical and mental stress due to better work-life balance, 6,16,37 better support systems and financial assistance, 16,28 improved nutrition, better hygiene, 8,12 reduced physical activity, 6,16,28,33 reduced exposure to infection, 8, 16, 37, 50 lower incidence of smoking and drug use due to reduced access and being indoors, 16 lower pollution exposure and levels in environment, 16,51 and fewer medical interventions secondary to reduced antenatal surveillance. 7,16,37,45 The differences in PTB findings between single-center/adjacent hospitals studies and national/regional studies could reflect a change in referral patterns due to reduced access or the fact that pregnant individuals opted to give birth in hospitals with lower prevalence of COVID-19 or in non-COVID designated hospitals.…”

“…All rights reserved While we did not observe an overall change in the odds of stillbirth during the pandemic period, several individual studies, mostly single-center in scope, reported increased odds of stillbirth compared to pre-pandemic time periods. The increase in stillbirth reported by these studies was attributed to reduced antenatal surveillance, a reluctance to access in-hospital care due to increased stress and anxiety, 9,18,30,33,39 or missed appointments due to rapid changes in maternity services during the pandemic. 50 These reasons may also explain an increase in maternal mortality identified in Mexico 34 ; however, according to authors the data from government website were preliminary in scope and may change as more data are available.…”

Effect of the COVID-19 pandemic on health facility delivery in Ethiopia; results from PMA Ethiopia’s longitudinal panel

“…A prospective observational study of pregnant women in Nepal examined data pre-and post-COVID-19 lockdown and identified a reduction in facility births of 52% [9]. In India, stillbirth rates among cohorts of women who delivered during COVID-19 period were found to be significantly higher than among women who delivered prior to COVID-19, primarily due to delays in reaching health care facilities and/or denial of care upon arrival [10]. A facility-based study in Ethiopia identified that fear of COVID-19 and interruption of services due to COVID-19 were associated with lower odds of receiving recommended antenatal care services [11].…”

Reproductive health crisis during waves one and two of the COVID-19 pandemic in India: Incidence and deaths from severe maternal complications in more than 202,000 hospital births

“…The high case-fatality could be due to a number of factors, including reductions in healthcare providers and medical supplies as a result of reallocation to mitigate the SARS-CoV-2 pandemic or a decrease in access and/or demand for healthcare services [2]. While the quality of care in the hospitals during the pandemic could have been compromised due to shortage of healthcare staff, converting hospital wards into SARS-CoV-2 treatment Units, and other administrative challenges [16] we cannot ignore access and demand as being a major risk factor for the increase in maternal deaths in the hospitals both due to a lack of transportation during lockdowns and 'hospital-avoiding' behaviour by pregnant women suggested by other studies [4,5,17].…”