COVID-19 and maternal and perinatal outcomes
Authors: Susannah Hopkins Leisher
Journal: The Lancet Global Health (2021)

The International Stillbirth Alliance welcomes the systematic review by Barbara Chmielewska and colleagues (June, 2021),1Chmielewska B Barratt I Townsend R et al.Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e759-e772Summary Full Text Full Text PDF PubMed Scopus (506) Google Scholar particularly its inclusion of stillbirths, because these are often missing from the global agenda. The 28% increased pooled odds in reported stillbirth during the COVID-19 pandemic is concerning. We wish to highlight some data limitations that will impede action to reduce these preventable deaths. First, most of the included studies were from high-income countries. If more studies from low-income and middle-income countries (LMICs), which have a higher burden, had been included, the authors might have found an even higher risk of stillbirth. Second, only one study disaggregated stillbirths by timing,2Kumar M Puri M Yadav R et al.Stillbirths and the COVID-19 pandemic: looking beyond SARS-CoV-2 infection.Int J Gynaecol Obstet. 2021; 153: 76-82Crossref PubMed Scopus (22) Google Scholar yet prevention efforts differ depending on whether stillbirths are antepartum or intrapartum. Third, although differing definitions of stillbirth were mentioned as a limitation of the review, the definitions themselves were (surprisingly) not reported. This inconsistency in definitions would have affected the comparability of the study results; and, more importantly, it obscures any COVID-19-related changes in stillbirth risk at different gestational ages. Fourth, only ten of the 22 studies that included either preterm birth or stillbirth included both outcomes. We have previously raised concerns on whether increased stillbirth is related to decreased preterm birth during the pandemic,3Homer CSE Leisher SH Aggarwal N et al.Counting stillbirths and COVID 19: there has never been a more urgent time.Lancet Glob Health. 2020; 9: e10-e11Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar so we note with interest this review's finding of decreased preterm birth in high-income countries and a decrease in the births of babies with a low birthweight.4Philip R Purtill H Reidy E et al.Unprecedented reduction in births of very low birthweight (VLBW) and extremely low birthweight (ELBW) infants during the COVID-19 lockdown in Ireland: a 'natural experiment' allowing analysis of data from the prior two decades.BMJ Glob Health. 2020; 5e003075Crossref PubMed Google Scholar Notably, analyses have shown that the inclusion of stillbirths increases preterm birth rates, with disproportionately larger increases in LMICs.5Morisaki N Ganchimeg T Vogel JP et al.Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of maternal and newborn health.BJOG. 2017; 124: 1346-1354Crossref PubMed Scopus (23) Google Scholar However, the included studies reveal study designs that essentially conceptualise preterm births and stillbirths as mutually exclusive (mirroring similar approaches in many health data collection systems), restricting understanding of COVID-19's full effect on perinatal outcomes. Fifth, a large number of studies (n=58) were excluded because of the absence of a comparison group or insufficient data, whereas a third of the included studies with a stillbirth outcome used comparison periods of just 2–3 months, highlighting the urgency of action by clinicians and researchers to ensure rigorous data. Finally, potentially relevant studies in LMICs were excluded because of the unavailability of published versions, and the exclusion of reviews meant that other potentially relevant data were also not captured. Given the severity of COVID-19 outcomes and the disproportionately higher risk of stillbirth in LMICs, we urge that future reviews encompass all relevant data to present a more holistic representation of the clinical reality. The International Stillbirth Alliance hopes that this concerning review encourages policy makers and health-care leaders to champion a comprehensive, consistent approach to the quality of care and monitoring of perinatal outcomes, along with the improved registration and reporting of stillbirths that this requires. We declare no competing interests. Counting stillbirths and COVID 19—there has never been a more urgent timeWe welcome the global stillbirth estimates published by UNICEF and WHO in October, 2020.1 These data indicate that there are at least 1·9 million stillbirths globally each year. The heavy public health burden of stillbirth has long remained invisible, despite more than a decade of sustained effort to raise it on the global health agenda. Ironically, even the recent BMJ collection,2 highlighting the UN guiding principle "Leave no one behind", omitted any mention of the 26 million women and families who will experience a stillbirth by 2030. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomesWe echo the call made by Barbara Chmielewska and colleagues1 for better data to capture the effects of COVID-19 on maternal outcomes. Our own systematic review (PROSPERO CRD42020219889, in progress) specifically focuses on the amount of maternal mortality as measured by the maternal mortality ratio, and our findings so far concur with their conclusion of an increase, but we advise caution in the interpretation of this trend. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomesWe commend Barbara Chmielewska and colleagues1 for undertaking a timely and comprehensive systematic review on a topic of pivotal global health importance. The increase in maternal mortality and stillbirths during the COVID-19 pandemic, particularly in low-resource settings, is of considerable concern. Although a substantial number of studies were collated, many have a substantial risk of bias. For example, of the 18 included studies assessing the link between the pandemic and preterm birth, only two had a quasi-experimental design, many did not have detailed methods, few adjusted for potential confounding factors, and only three included population-level data. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomes – Authors' replyWe thank all correspondents for their interest in our report.1 A common point is the need for better quality studies in this area, which we wholeheartedly echo. Quality and consistency in reporting, particularly of key outcomes such as maternal death, stillbirth, and preterm birth, are essential if we are to tackle these scourges of maternity care. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomesIn their systematic review and meta-analysis, Barbara Chmielewska and colleagues1 note significant increases in maternal death and stillbirths during the COVID-19 pandemic. They link these outcomes to reduced access to maternal health services, stating that in low-income and middle-income countries (LMICs), remote antenatal care appointments are less feasible because of technological shortcomings in these countries. Full-Text PDF Open AccessEffects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysisGlobal 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. Full-Text PDF Open Access