Exploring modifiable risk-factors for premature birth in the context of COVID-19 mitigation measures: A discussion paper

Impact of COVID-19 mitigation measures on perinatal outcomes in the Netherlands

OBJECTIVE

Investigate the acute impact of COVID-19 mitigation measures implemented in March 2020 on a comprehensive range of perinatal outcomes.

STUDY DESIGN

National registry-based quasi-experimental study.

METHODS

We obtained data from the Dutch Perinatal Registry (2010-2020) which was linked to multiple population registries containing sociodemographic variables. A difference-in-discontinuity approach was used to examine the impact of COVID-19 mitigation measures on various perinatal outcomes. We investigated preterm birth incidence across onset types, alongside other perinatal outcomes including low birth weight, small-for-gestational-age, NICU admission, low-APGAR-score, perinatal mortality, neonatal death, and stillbirths.

RESULTS

The analysis of the national-level dataset revealed a consistent pattern of reduced preterm births after the enactment of COVID-19 mitigation measures on March 9, 2020 (OR = 0.80, 95% CI 0.68-0.96). A drop in spontaneous preterm births post-implementation was observed (OR = 0.80, 95% CI 0.62-0.98), whereas no change was observed for iatrogenic births. Regarding stillbirths (OR = 0.95, 95% CI 0.46-1.95) our analysis did not find compelling evidence of substantial changes. For the remaining outcomes, no discernible shifts were observed.

CONCLUSIONS

Our findings confirm the reduction in preterm births following COVID-19 mitigation measures in the Netherlands. No discernible changes were observed for other outcomes, including stillbirths. Our results challenge previous concerns of a potential increase in stillbirths contributing to the drop in preterm births, suggesting alternative mechanisms.

Preterm birth and stillbirth during COVID-19 pandemic in Bihor County/Romania

Background

International studies have reported conflicting data about the effects of COVID-19 pandemic policy measures on maternal and neonatal health. A major impact was reported on stillbirth and prematurity. The published literature suggests that the economic setting influenced the effects of imposed mitigation measures with a more severe effect in low-income countries.

Objectives

Our objective is to compare pregnancy outcomes at the only tertiary Maternity Hospital in Bihor County-Romania before and during the COVID-19 pandemic. This study aims to observe and document differences in perinatal outcomes across these periods, without inferring direct causation related to the pandemic or its associated restrictions.

Materials and methods

We used data from the registries of Public Health Services Bihor to conduct a retrospective cohort analysis of preterm births and stillbirths during the COVID-19 pandemic in Bihor County, Romania. Pregnancy outcomes were compared between the pandemic period (March 2020-February 2022) to the corresponding historical pre-COVID-19 period (March 2018-February 2020). Maternal socio-demographic variables and neonatal characteristics of these periods were also examined.

Results

The COVID-19 pandemic period was associated with an increase in the stillbirth rate (RR: 1.53, 95% CI, 1.05-2.23). Preterm birth was significantly impacted during this period and showed changes when analyzing gestational age (RR: 0.88, 95% CI, 0.79-0.96) or birth weight (RR: 0.91, 95% CI, 0.82-1.00). The main cause of stillbirth was intrauterine asphyxia due to placental causes (67.6%) or cord pathology (12.6%), the most frequently encountered maternal pathology was cardiovascular (28.3%) or infectious (21.7%). Our study revealed no significant changes in terms of maternal and neonatal characteristics during the two-year pandemic period.

Conclusions

Lockdown restrictions in Bihor County, Romania were associated with an increase in stillbirths, whilst preterm birth rate decreased. This raises concerns about whether pandemic policy measures may have led to a failure in identifying and offering proper care for pregnant women who were more likely to experience an antepartum loss. Further studies across the globe are needed in order to integrate comparable data that will help develop adequate protocols and policies for protecting maternal and child health during the next pandemic that will follow.

SARS-CoV-2 in Pregnancy-A Retrospective Analysis of Selected Maternal and Fetal Laboratory Parameters

Pregnant women and their neonates belong to the group of individuals with elevated risk for COVID-19 infection. Data on the course of the disease and how it affects the pregnancy and neonatal wellbeing remain conflicting. The aim of the study was to evaluate the effect of SARS CoV-2 infection on the mode of delivery, neonatal condition and selected maternal and fetal laboratory parameters. This was a single-center retrospective case-control study. This dataset was generated using electronic medical records collected by medical personnel. Two groups of patients, hospitalized between April, 2020 and February, 2021, were included in the study: study group (304)-pregnant women with SARS-CoV-2 and control group (N = 329)-healthy pregnant women or parturients. Mothers with a severe course of COVID-19 had higher activated partial thromboplastin-APTT (p = 0.02), C-Reactive Protein-CRP (p = 0.00) and procalcitonin (p = 0.032) levels as compared to pregnant women with mild or moderate course of the disease. Neonates born to SARS-CoV-2-infected mothers presented with worse condition at 1 and 5 minutes of life (p = 0.000 and 0.00, respectively) and lower Arterial Blood Gas-ABG pH scores (p = 0.016). Elective cesarean section is the most common mode of delivery for SARS-CoV2-infected mothers. Emergency cesarean sections are performed at earlier gestational age as compared to vaginal delivery and elective cesarean section. Lower Apgar scores were observed in neonates born to SARS-CoV-2-infected mothers who required oxygen therapy and whose procalcitonin levels were elevated. There is a relationship between more severe course of COVID-19 and APTT, as well as CRP and procalcitonin levels.

Interrupted-time-series analysis of the immediate impact of COVID-19 mitigation measures on preterm birth in China

Preliminary evidence from China and other countries has suggested that coronavirus disease 2019 (COVID-19) mitigation measures have caused a decline in preterm births, but evidence is conflicting. Utilising a national representative data of 11,714,947 pregnant women in China, we explored the immediate changes in preterm birth rates during the COVID-19 mitigation period using an interrupted-time-series analysis. We defined the period prior to February 1, 2020 as the baseline, followed by the COVID-19 mitigation stage. In the first month of the COVID-19 mitigation, a significant absolute decrease in preterm birth rates of 0.68% (95%CI:−1.10% to −0.26%) in singleton, and of 2.80% (95%CI:−4.51% to −1.09%) in multiple births was noted. This immediate decline in Wuhan was greater than that at the national level among singleton births [−2.21% (95%CI:−4.09% to −0.34% vs. −0.68%)]. Here we report an immediate impact of COVID-19 mitigation measures on preterm birth in China.

The broader impacts of COVID-19 mitigation measures may include changes in the incidence of preterm birth. Here, the authors use data from ~11.7 million pregnancies in China and find evidence of a small decline in preterm birth rates immediately following the implementation of COVID-19 mitigation measures.

Prevalence of Preterm Births and Complications of Prematurity: A Comparison Between First Year of COVID-19 Pandemic and the Previous Year

Background: COVID-19 pandemic imposed significant challenges on the health systems. COVID-19 management policies such as lockdown have made access to the health centers difficult. Pregnant women are a high-risk group whose pregnancy outcomes may be affected by COVID-19 pandemic. So, it is necessary to determine changes in the prevalence of preterm births and complications of prematurity during the pandemic. Objectives: This study aimed to determine the prevalence of preterm births and complications of prematurity during the first year of COVID-19 pandemic compared with the previous year. Methods: In this cross-sectional study, we included all live births born between March 2019 to March 2021 in Mahdieh hospital, Tehran, Iran. We reviewed medical records to extract the prevalence of preterm births and prematurity complications. Then, the prevalence of preterm births and prematurity complications during COVID-19 pandemic compared with the previous year. We used Chi-square test to analyze categorical variables. Results: A total of 10,830 live births were included in this study. During COVID-19 pandemic, the prevalence of moderate or late prematurity had a 4.64% reduction (P < 0.001), and the prevalence of term birth increased by 5.37% (P < 0.001) compared with the previous year. The prevalence of respiratory distress syndrome (RDS) decreased significantly during COVID-19 pandemic compared with the previous year (23.64% vs. 26.56%, P < 0.001). The prevalence of retinopathy of prematurity (ROP) significantly increased during COVID-19 pandemic compared with the previous year (3.97% vs. 2.28%, P < 0.001). Additionally, sepsis was significantly more prevalent during COVID-19 pandemic compared with the previous year (6.84% vs. 1.23%, P < 0.001). Moreover, intraventricular hemorrhage (IVH) significantly increased during COVID-19 pandemic in comparison to the previous year (1.10% vs. 0.08%, P < 0.001). Conclusions: The prevalence of preterm birth decreased during COVID-19 lockdown. Also, major complications of prematurity such as RDS, ROP, sepsis, and IVH may be affected by COVID-19 lockdown.

Threatened abortion, threatened premature labor, and preterm birth during the first state of emergency for COVID-19 in 2020 in Japan

AIM

This study examined the maternal experience of threatened abortion, threatened premature labor, or preterm birth before, during, and after the first state of emergency for COVID-19 in 2020 in Japan.

METHODS

This was a cross-sectional, internet-based questionnaire survey. We recruited 600 postpartum women and divided them into three groups by date of delivery: before (October 2019-March 2020), during (April-May 2020), and after (June-October 2020) the first state of emergency. The outcome was the presence of at least one of the following complications: threatened abortion, threatened premature labor, and/or preterm birth. The prevalence ratios (PRs) of the outcome were calculated and compared among the three groups using a multivariable Poisson regression model with adjustment for potential confounders.

RESULTS

Of the 553 women eligible for analysis, those who delivered during (PR 0.69, 95% confidence interval [CI] 0.47-0.99) and after (PR 0.62, 95% CI 0.42-0.90) the state of emergency were less likely to have experienced either threatened abortion, threatened premature labor, or preterm birth than those who delivered before the state of emergency. Among the adjustment variables, smoking at the time of survey (PR 1.68, 95% CI 1.01-2.80) and living in the prefectures with a population of >5 million (PR 0.71, 95% CI 0.51-0.97) were associated with the study outcome.

CONCLUSION

Threatened abortion, threatened premature labor, or preterm birth appeared to decrease during and after the first state of emergency in 2020. The longitudinal effects of coronavirus disease on maternal and newborn health should be monitored continuously.

Nursing care recommendation for pediatric COVID-19 patients in the hospital setting: A brief scoping review

BACKGROUND

The hospitalization of children during the COVID-19 pandemic has affected their physical and mental health. Pediatric nurses have faced challenges in providing high-quality nursing care for children and their families. However, the pediatric nursing care recommendations for COVID-19 patients in the hospital setting remain unclear. The current scoping review provides recommendations for nursing interventions for pediatric COVID-19 patients in the hospital setting.

METHODS AND FINDINGS

The selected articles containing management and nursing recommendations for COVID-19 that have occurred in pediatric patients ages 0-19 years old. A search strategy was developed and implemented in seven databases. We included peer-reviewed articles that reported observational or interventional studies, as well as policy papers, guides or guidelines, letters and editorials, and web articles. A total of 134 articles and other documents relevant to this review were included. We categorized the results based on The Nursing Intervention Classification (NIC) taxonomy which consists of six domains (e.g., Physiological: Basic); eleven classes (e.g., Nutrition Support); and eighteen intervention themes (e.g., Positioning, Family Presence Facilitation, Family Support, and Discharge Planning).

CONCLUSION

Apart from the intervention of physical problems, there is a need to promote patient- and family-centered care, play therapy, and discharge planning to help children and families cope with their new situation.

Breastfeeding in the context of the COVID-19 pandemic: A discussion paper

Breastfeeding offers one of the most fundamental global health benefits for babies. Breastmilk is lifesaving, providing not only nutrition but immunologic benefits and as such is strongly supported by the World Health Organization and leading healthcare associations worldwide. When the COVID-19 pandemic started in 2020, the impact of the restrictions to prevent the spread of the disease created challenges and questions about provision of safe, quality care, including breastfeeding practices, in a new 'normal' environment. Mothers were temporarily separated from their babies where infection was present or suspected, parents were prevented from being present on neonatal units and vital breastfeeding support was prevented. This discussion paper provides an overview of essential areas of knowledge related to practice for neonatal nurses and midwives who care for breastfeeding mothers and babies, in the context of the COVID-19 pandemic and the latest global guidance. Three areas will be discussed; the protective benefits of breastfeeding, keeping breastfeeding mothers and babies together and supporting mothers to breastfeed their babies. Finally, care recommendations are presented to serve as a summary of key points for application to practice for neonatal nurses and midwives.

Assessment of Seasonality and Extremely Preterm Birth in Denmark

IMPORTANCE

Preterm birth, particularly extremely preterm birth, has been associated with substantial morbidity and mortality. Research during SARS-CoV-2-related lockdowns revealed reductions in the more severe subtypes of preterm birth in some countries, suggesting the presence of preventable risk factors, such as infectious diseases or social behavior. Seasonality may provide a similar means of assessing natural changes in the daily life of pregnant individuals that were similar to those experienced during the COVID-19 lockdown period.

OBJECTIVE

To evaluate the association between seasonality and extremely preterm birth.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cohort study included 1 136 143 pregnancies in Denmark with onset between January 1, 1997, and December 31, 2016, in which the fetuses survived 21 completed weeks of gestation. Pregnancies were followed up until preterm birth, fetal death, or 37 completed weeks of gestation. Data were analyzed from September 2020 to September 2021.

EXPOSURES

Season during gestation (primary exposure) and season of pregnancy onset.

MAIN OUTCOMES AND MEASURES

The main outcome of extremely preterm birth was defined as a live birth occurring between 22 weeks, 0 days' gestation and 27 weeks, 6 days' gestation. Cox regression analyses were used to estimate hazard ratios (HRs) for season during gestation and season of pregnancy onset, with adjustment for socioeconomic and demographic factors.

RESULTS

Among 662 338 pregnant individuals, the median age at pregnancy onset was 30.0 years (IQR, 6.0 years). Of 1 136 143 pregnancies, 2009 extremely preterm births (cumulative incidence, 0.18%) were identified during follow-up. Season during gestation was associated with extremely preterm birth, with cumulative incidences of 0.17% (95% CI, 0.16%-0.19%) in spring, 0.18% (95% CI, 0.17%-0.20%) in summer, 0.20% (95% CI, 0.18%-0.21%) in autumn, and 0.16% (95% CI, 0.14%-0.17%) in winter. Compared with winter, the adjusted HRs (AHRs) for the risk of extremely preterm birth were 1.11 (95% CI, 0.97-1.26) for spring, 1.15 (95% CI, 1.02-1.31) for summer, and 1.25 (95% CI, 1.10-1.42) for autumn. The number of extremely preterm births associated with the increased risk in the spring, summer, and autumn was 56.1 (95% CI, 18.2-99.7), representing 2.8% (95% CI, 0.9%-5.0%) of all extremely preterm births in the study. Season of pregnancy onset was not associated with the risk of extremely preterm birth in spring (AHR, 0.98; 95% CI, 0.95-1.01) or summer (AHR, 1.00; 95% CI, 0.96-1.03) compared with winter, but a slight increase in risk was observed in autumn (AHR, 1.05; 95% CI, 1.02-1.09) compared with winter.

CONCLUSIONS AND RELEVANCE

In this large, national cohort study, seasonality was associated with 2.8% of all extremely preterm births. Season during gestation was associated with the rate of extremely preterm birth, suggesting the presence of potential risk factors associated with season that may be preventable. Further research to identify risk factors for extremely preterm birth associated with seasonality is warranted.

Preterm births in South-West England before and during the COVID-19 pandemic: an audit of retrospective data

The COVID-19 lockdown had a series of intended and unintended consequences, including reduced infections and changes in activities and behaviours. Some of these changes may have been beneficial to perinatal outcomes; however, other factors such as reduced access to face-to-face healthcare may have contributed negatively to antenatal care. The aim of this audit was to evaluate neonatal admissions in the South-West of England during the COVID-19 pandemic in 2020 and the previous two years 2018-2019. Anonymised birth and neonatal admission rates from January to December 2020 was obtained and compared to data from 2018 to 2019. The results demonstrate a decreasing in neonatal unit admissions between 2018 and 2020, 9.48% of live births in 2018 (95% CI 9.17, 9.80) to 8.89% (95% CI 8.65, 9.13) in 2020 (p = 0.002).Conclusion: There were no significant differences across gestational groups. It is unclear without nationwide data whether our observed trends, decreased neonatal admissions over the past 3 years, are generalisable and related to the COVID-19 pandemic. Future research exploring the impact of lockdowns on behaviour change during pregnancy and support services is warranted to understand the implications of pandemics on pregnancy and preterm birth. What is Known: • The COVID-19 lockdown had a series of intended and unintended consequences; some of which may have been beneficial to perinatal outcomes. • Research suggests that preterm births have not significantly changed overall, but they have decreased in high-income countries. What is New: • In our audit, analysing retrospective data of regional birth and neonatal admission from the South-West of England, we observed a decrease in live birth rates between 2018 and 2020. • A reduction in neonatal unit admissions was observed from 2018 to 2020 with no significant differences across gestational groups. The reduction from 2019 to 2020 was smaller than that from 2018 to 2019 implying that the COVID-19 pandemic in 2020 was not necessarily implicated.