COVID-19 and maternal and perinatal outcomes – Authors' reply
Authors: 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 A Magee, Asma Khalil
Journal: The Lancet Global Health (2021)

We thank all correspondents for their interest in our report.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 (627) Google Scholar 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. As always, systematic reviews are restricted to covering what has been published. Susannah Leisher and the International Stillbirth Alliance call for the inclusion of a relevant preprint paper. We recognised that the COVID-19 literature is a rapidly evolving field with high rates of preprint publication. In consultation with editors and reviewers, however, we agreed to exclude such papers to avoid the pseudo-inflation of the sample size and undermine confidence in the findings of the analysis, but acknowledge that this exclusion might have a greater effect on data from LMICs, which are recognised to be less likely to secure publication. We agree with Clara Calvert and colleagues, and did highlight in our Article, that the finding of an increase in maternal mortality relied on just two data sources, only one of which presented national-level data. The finding is consistent with another report from India not included in the quantitative analysis,2Goyal M Singh P Singh K Shekhar S Agrawal N Misra S The effect of the COVID-19 pandemic on maternal health due to delay in seeking health care: experience from a tertiary center.Int J Gynaecol Obstet. 2021; 152: 231-235Crossref PubMed Scopus (135) Google Scholar and with national-level evidence from Kenya reported in a preprint publication.3Shikuku D Nyaoke I Gichuru S et al.Early indirect impact of COVID-19 pandemic on utilization and outcomes of reproductive, maternal, newborn, child and adolescent health services in Kenya.medRxiv. 2020; (published online Sept 9.) (preprint).https://doi.org/10.1101/2020.09.09.20191247Google Scholar But we agree that this early identification of increased maternal mortality cannot necessarily be extrapolated throughout the global population and that further investigation is required. We share Lizbeth Ochoa and colleagues' confidence in the finding that preterm birth seems to have decreased, in high-income countries at least, during the COVID-19 pandemic. We support their call for further robust investigations using population-level data of a high quality and considering stillbirth and preterm birth together. They suggest that we should have included another study in the quantitative synthesis.4Been JV Burgos Ochoa L Bertens LCM Schoenmakers S Steegers EAP Reiss IKM Impact of COVID-19 mitigation measures on the incidence of preterm birth: a national quasi-experimental study.Lancet Public Health. 2020; 5: e604-e611Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar However, we were unable to include this otherwise excellent study because the report included four different time frames around three different implementation dates without extractable raw data. We read with interest Zeus Aranda and colleagues' experiences in delivering maternity care at their Partners in Health project sites and congratulate them on their successes. Key lessons include the importance of responses to local need based on acceptable and available models of care and resources, highlighted in their community health worker programmes in Lesotho, Malawi, and Mexico. The response to the COVID-19 pandemic has driven an explosion in remote access to health care, community reporting, and the use of technology in a diverse range of settings. We should use this opportunity to improve the coverage of pregnancy and neonatal surveillance data. EM reports grants from Chugai Pharma and Gedeon Richter; personal fees from Gedeon Richter and Pfizer; and other from Chugai Pharma and Kebomed, outside the submitted work; and is the president and a trustee of Royal College of Obstetricians & Gynaecologists, is a trustee of the British Menopause Society; and is the chair of trustees for Group B Strep Support. All other authors declare no competing interests. COVID-19 and maternal and perinatal outcomesThe International Stillbirth Alliance welcomes the systematic review by Barbara Chmielewska and colleagues (June, 2021),1 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. 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 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