COVID-19 and maternal and perinatal outcomes
Authors: Lizbeth Burgos Ochoa, Meredith Brockway, Sarah J Stock, Jasper V Been
Journal: The Lancet Global Health (2021)

We commend Barbara Chmielewska and colleagues1Chmielewska 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 (507) Google Scholar 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. Only one study accounted for time trends in preterm birth,2Been 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 (154) Google Scholar which is important to ensure that any changes during the pandemic are independent of underlying temporal patterns. Of the 18 studies, that study also had the largest sample size and the maximum Newcastle-Ottawa score, indicating a high quality. Because systematic reviews serve an important role in summarising the best available evidence, it is remarkable that the meta-analysis by Chmielewska and colleagues excluded this study. Using inverse-variance rather than Mantel-Haenszel weighting allows for its inclusion,3Egger M Smith GD Altman DG Systematic reviews in health care: meta-analysis in context. BMJ Books, London2001Crossref Scopus (300) Google Scholar with little effect on the association between the COVID-19 pandemic and preterm birth (odds ratio [OR] 0·90; 95% CI 0·83–0·98; 13 studies; n=1 919 726 [figure] compared with 0·91; 0·84–0·99; 12 studies; n=852 854).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 (507) Google Scholar A thorough assessment of how the COVID-19 pandemic and lockdowns have affected maternal and perinatal outcomes is crucial and has important public health implications. Accordingly, more robust studies are needed that are based on high-quality longitudinal data. Ideally, population-level data should be used, because the pandemic probably influenced health-seeking behaviours and access to maternity care, leading to potential ascertainment bias if institutional-level data are relied on.4KC A Gurung R Kinney MV et al.Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study.Lancet Glob Health. 2020; 8: e1273-e1281Summary Full Text Full Text PDF PubMed Scopus (272) Google Scholar Also, the inclusion of both pregnancy and neonatal data (rather than just one or the other) is important to assess any disparate effect of the pandemic on competing events (eg, stillbirth and preterm birth). Applying appropriate quasi-experimental designs to population-level maternity and birth data, accounting for underlying temporal trends in the outcomes of interest, has the highest potential to attribute causality and reduce confounding. Now is the time for the perinatal research community to collaboratively take advantage of the unique natural experiment provided by the COVID-19 pandemic to accelerate progress in maternal and child health globally. We call on researchers to undertake robust studies and contribute to joint international efforts such as the international Perinatal Outcomes in the Pandemic (iPOP) study.5Stock SJ Zoega H Brockway M et al.The international Perinatal Outcomes in the Pandemic (iPOP) study: protocol.Wellcome Open Res. 2021; 6: 21Crossref PubMed Scopus (13) Google Scholar Together we can learn from experiences from the pandemic and start identifying mechanisms that might contribute to a healthier start for future generations. SJS reports grants supplied to the University of Edinburgh by the Wellcome Trust, the National Institute of Healthcare Research, the Chief Scientist Office, and the Medical Research Council. LBO and JVB were authors on Been and colleagues (2020). MB and SJS are co-leads for the iPOP study and JVB is on the iPOP data analysis team. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational studyInstitutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. Full-Text PDF Open AccessCOVID-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 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