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Thacher JD, Vilhelmsson A, Blomberg AJ, Rylander L, Jöud A, Schmidt L, Hougaard CØ, Elmerstig E, Vassard D, Mattsson K. Influence of the COVID-19 pandemic on births and induced abortions in Southern Sweden: a register-based study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2023-202162. [PMID: 38834283 DOI: 10.1136/bmjsrh-2023-202162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Pandemics are linked with declining birth rates, but little is known about how the COVID-19 pandemic has influenced childbearing decisions. We aimed to investigate the associations between the COVID-19 pandemic and reproductive decisions, specifically to identify potential changes in the frequency of deliveries and induced abortions in Skåne, Sweden. METHODS Using the Skåne Healthcare Register, we identified women aged 15-45 years who had at least one pregnancy-related care visit registered between 1 January 2013 and 11 November 11 2021. Deliveries and induced abortions were identified, and changes in weekly delivery and abortion counts were assessed using an interrupted time series design. Relative risks (RRs) and 95% confidence intervals (CIs) were estimated from a Poisson regression model. RESULTS During the study period we identified 129 131 deliveries and 38 591 abortions. Compared with the counterfactual (exposed interval assuming COVID-19 had not occurred), pandemic exposure was associated with fewer deliveries (RR 0.93; 95% CI 0.89 to 0.98). For abortions, pandemic exposure appeared to be associated with fewer abortions (RR 0.95; 95% CI 0.90 to 1.00); however, age-related differences were found. Among women aged 25 years and over, pandemic exposure was more strongly associated with fewer abortions. Contrastingly, among women aged under 25 years, abortions appeared to increase. CONCLUSIONS The COVID-19 pandemic seemed to have contributed to a decline in births in Southern Sweden. During the same period, abortions declined in women in the older age range, but contrastingly increased among younger women.
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Affiliation(s)
- Jesse D Thacher
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Andreas Vilhelmsson
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Annelise J Blomberg
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Lars Rylander
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Anna Jöud
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Department of Research and Development, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Lone Schmidt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Eva Elmerstig
- Department of Social Work, Centre for Sexology and Sexuality Studies, Malmö University, Malmö, Sweden
| | - Ditte Vassard
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Mattsson
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
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Dörr T, Güsewell S, Cusini A, Brucher A, Goppel S, Grässli F, Betschon E, Möller J, Ortner M, Ruetti M, Stocker R, Vuichard‐Gysin D, Besold U, Risch L, von Kietzell M, Schlegel M, Kuster S, Kahlert C, Kohler P. SARS-CoV-2 Vaccination is Not Associated With Involuntary Childlessness in Female Healthcare Workers: A Multicenter Cohort Study. Influenza Other Respir Viruses 2024; 18:e13333. [PMID: 38845394 PMCID: PMC11157148 DOI: 10.1111/irv.13333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND There is debate about the causes of the recent birth rate decline in high-income countries worldwide. During the pandemic, concern about the effects on reproductive health has caused vaccine hesitancy. We investigated the association of SARS-CoV-2 vaccination and infection with involuntary childlessness. METHODS Females in fertility age within a prospective multicenter cohort of healthcare workers (HCW) were followed since August 2020. Data on baseline health, SARS-CoV-2-infection, and vaccination were obtained and regularly updated, in which serum samples were collected repetitively and screened for anti-nucleocapsid and anti-spike antibodies. In October 2023, participants indicated the presence of involuntary childlessness with onset during the pandemic, whereas those indicating an onset before the pandemic were excluded. The association of involuntary childlessness and SARS-CoV-2-vaccination and infection was investigated using univariable and multivariable analysis. Sensitivity analysis was performed to compare those reporting involuntary childlessness with those birthing a child since 2020. RESULTS Of 798 participants, 26 (3.2%) reported involuntary childlessness starting since the pandemic. Of the involuntary childless women, 73.1% (19/26) were vaccinated compared to 86.0% (664/772) without involuntary childlessness (p = 0.73). SARS-CoV-2 infection was reported by 76.9% (20/26) compared to 72.4% (559/772) of controls (p = 0.64). Neither SARS-CoV-2 vaccination (aOR 0.91 per dose, 95%CI 0.67-1.26) nor infection (aOR per infection 1.05, 95%CI 0.62-1.71) was associated with involuntary childlessness. Sensitivity analysis confirmed these results. CONCLUSIONS Among female HCW of fertility age, 3.2% indicated involuntary childlessness, which is comparable to pre-pandemic data. No association between involuntary childlessness and SARS-CoV-2 vaccination or infection was found.
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Affiliation(s)
- Tamara Dörr
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
| | - Sabine Güsewell
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
| | - Alexia Cusini
- Division of Infectious DiseasesCantonal Hospital GraubündenChurSwitzerland
| | - Angela Brucher
- Psychiatry Services of the Canton of St. Gallen (South)St GallenSwitzerland
| | - Stephan Goppel
- Ambulatory ServicesPsychiatry Services of the Canton of St. Gallen (North)St. GallenSwitzerland
| | - Fabian Grässli
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
| | | | | | - Manuela Ortner
- Rheintal Werdenberg Sarganserland Hospital GroupGrabsSwitzerland
| | - Markus Ruetti
- Fuerstenland Toggenburg Hospital GroupWilSwitzerland
| | | | - Danielle Vuichard‐Gysin
- Division of Infectious Diseases and Hospital EpidemiologyThurgau Hospital GroupMuensterlingenSwitzerland
- Department of Research and DevelopmentSwiss National Centre for Infection Prevention (Swissnoso)BerneSwitzerland
| | | | - Lorenz Risch
- Labormedizinisches Zentrum Dr Risch Ostschweiz AGBuchsSwitzerland
- Private Universität im Fürstentum LiechtensteinTriesenLiechtenstein
- Centre of Laboratory MedicineUniversity Institute of Clinical Chemistry, University of Bern, InselspitalBernSwitzerland
| | | | - Matthias Schlegel
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
| | - Stefan P. Kuster
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
| | - Christian R. Kahlert
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
- Department of Infectious Diseases and Hospital EpidemiologyChildren's Hospital of Eastern SwitzerlandSt. GallenSwitzerland
| | - Philipp Kohler
- Division of Infectious Diseases and Hospital EpidemiologyCantonal Hospital St GallenSt GallenSwitzerland
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3
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Abderhalden-Zellweger A, de Labrusse C, Gemperle M, Grylka-Baeschlin S, Pfund A, Mueller AN, Mariani I, Pessa Valente E, Lazzerini M. Women's experiences of disrespect and abuse in Swiss facilities during the COVID-19 pandemic: a qualitative analysis of an open-ended question in the IMAgiNE EURO study. BMC Pregnancy Childbirth 2024; 24:402. [PMID: 38822258 PMCID: PMC11143635 DOI: 10.1186/s12884-024-06598-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 05/21/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has challenged the provision of maternal care. The IMAgiNE EURO study investigates the Quality of Maternal and Newborn Care during the pandemic in over 20 countries, including Switzerland. AIM This study aims to understand women's experiences of disrespect and abuse in Swiss health facilities during the COVID-19 pandemic. METHODS Data were collected via an anonymous online survey on REDCap®. Women who gave birth between March 2020 and March 2022 and answered an open-ended question in the IMAgiNE EURO questionnaire were included in the study. A qualitative thematic analysis of the women's comments was conducted using the International Confederation of Midwives' RESPECT toolkit as a framework for analysis. FINDINGS The data source for this study consisted of 199 comments provided by women in response to the open-ended question in the IMAgiNE EURO questionnaire. Analysis of these comments revealed clear patterns of disrespect and abuse in health facilities during the COVID-19 pandemic. These patterns include non-consensual care, with disregard for women's choices and birth preferences; undignified care, characterised by disrespectful attitudes and a lack of empathy from healthcare professionals; and feelings of abandonment and neglect, including denial of companionship during childbirth and separation from newborns. Insufficient organisational and human resources in health facilities were identified as contributing factors to disrespectful care. Empathic relationships with healthcare professionals were reported to be the cornerstone of positive experiences. DISCUSSION Swiss healthcare facilities showed shortcomings related to disrespect and abuse in maternal care. The pandemic context may have brought new challenges that compromised certain aspects of respectful care. The COVID-19 crisis also acted as a magnifying glass, potentially revealing and exacerbating pre-existing gaps and structural weaknesses within the healthcare system, including understaffing. CONCLUSIONS These findings should guide advocacy efforts, urging policy makers and health facilities to allocate adequate resources to ensure respectful and high-quality maternal care during pandemics and beyond.
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Affiliation(s)
- Alessia Abderhalden-Zellweger
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue de Beaumont 21, 1011, Lausanne, Switzerland.
| | - Claire de Labrusse
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue de Beaumont 21, 1011, Lausanne, Switzerland
| | - Michael Gemperle
- Research Institute of Midwifery and Reproductive Health, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Susanne Grylka-Baeschlin
- Research Institute of Midwifery and Reproductive Health, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Anouck Pfund
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue de Beaumont 21, 1011, Lausanne, Switzerland
| | - Antonia N Mueller
- Research Institute of Midwifery and Reproductive Health, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Ilaria Mariani
- WHO Collaborating Center for Maternal and Child Health, Institute for Maternaland , Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Emanuelle Pessa Valente
- WHO Collaborating Center for Maternal and Child Health, Institute for Maternaland , Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Marzia Lazzerini
- WHO Collaborating Center for Maternal and Child Health, Institute for Maternaland , Child Health IRCCS "Burlo Garofolo", Trieste, Italy
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García-Lara NR, Escuder-Vieco D, Cabrera-Lafuente M, Keller K, De Diego-Poncela C, Jiménez-González C, Núñez-Ramos R, Flores-Antón B, Escribano-Palomino E, Alonso-Díaz C, Vázquez-Román S, Ureta-Velasco N, Cruz-Bértolo JDL, Pallás-Alonso CR. Clinical Impact of Supplementation with Pasteurized Donor Human Milk by High-Temperature Short-Time Method versus Holder Method in Extremely Low Birth Weight Infants: A Multicentre Randomized Controlled Trial. Nutrients 2024; 16:1090. [PMID: 38613123 PMCID: PMC11013736 DOI: 10.3390/nu16071090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024] Open
Abstract
Nosocomial infections are a frequent and serious problem in extremely low birth weight (ELBW) infants. Donor human milk (DHM) is the best alternative for feeding these babies when mother's own milk (MOM) is not available. Recently, a patented prototype of a High-Temperature Short-Time (HTST) pasteurizer adapted to a human milk bank setting showed a lesser impact on immunologic components. We designed a multicentre randomized controlled trial that investigates whether, in ELBW infants with an insufficient MOM supply, the administration of HTST pasteurized DHM reduces the incidence of confirmed catheter-associated sepsis compared to DHM pasteurized with the Holder method. From birth until 34 weeks postmenstrual age, patients included in the study received DHM, as a supplement, pasteurized by the Holder or HTST method. A total of 213 patients were randomized; 79 (HTST group) and 81 (Holder group) were included in the analysis. We found no difference in the frequency of nosocomial sepsis between the patients of the two methods-41.8% (33/79) of HTST group patients versus 45.7% (37/81) of Holder group patients, relative risk 0.91 (0.64-1.3), p = 0.62. In conclusion, when MOM is not available, supplementing during admission with DHM pasteurized by the HTST versus Holder method might not have an impact on the incidence of catheter-associated sepsis.
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Affiliation(s)
- Nadia Raquel García-Lara
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Diana Escuder-Vieco
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Marta Cabrera-Lafuente
- Department of Neonatology, La Paz University Hospital, 28046 Madrid, Spain; (M.C.-L.); (C.J.-G.); (E.E.-P.)
- Institute for Health Research–IdiPaz, La Paz University Hospital, 28046 Madrid, Spain
| | - Kristin Keller
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Cristina De Diego-Poncela
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
| | - Concepción Jiménez-González
- Department of Neonatology, La Paz University Hospital, 28046 Madrid, Spain; (M.C.-L.); (C.J.-G.); (E.E.-P.)
- Institute for Health Research–IdiPaz, La Paz University Hospital, 28046 Madrid, Spain
| | - Raquel Núñez-Ramos
- Department of Pediatric Nutrition, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Beatriz Flores-Antón
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Esperanza Escribano-Palomino
- Department of Neonatology, La Paz University Hospital, 28046 Madrid, Spain; (M.C.-L.); (C.J.-G.); (E.E.-P.)
- Institute for Health Research–IdiPaz, La Paz University Hospital, 28046 Madrid, Spain
| | - Clara Alonso-Díaz
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Sara Vázquez-Román
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Noelia Ureta-Velasco
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
| | - Javier De La Cruz-Bértolo
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
- Clinical Research Platform IC+12, Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Carmen Rosa Pallás-Alonso
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain; (C.D.D.-P.); (B.F.-A.); (C.A.-D.); (S.V.-R.); (N.U.-V.); (C.R.P.-A.)
- Aladina-MGU-Regional Human Milk Bank, 12 de Octubre University Hospital, 28041 Madrid, Spain; (D.E.-V.); (K.K.)
- Research Institute i+12, 12 de Octubre University Hospital, 28041 Madrid, Spain;
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Mooi-Reci I, Wooden M, Zilio F. Baby Bump or Baby Slump? COVID-19, Lockdowns, and their Effects on Births in Australia. SSM Popul Health 2024; 25:101604. [PMID: 38292050 PMCID: PMC10825770 DOI: 10.1016/j.ssmph.2024.101604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
This study examines changes in birth rates in Australia during the COVID-19 pandemic and the extent to which such changes were influenced by lockdowns. We use natality data at State and small regional area levels spanning the period from 2011 to 2022. In our empirical approach, we first take advantage of a unique quasi-experimental setting that arose in Victoria, Australia's second most populous State, during the first year of the pandemic. Victoria imposed a 111-day stay-at-home lockdown while other States and Territories enforced milder restrictions on social and economic activities. We then exploit lockdowns that lasted more than three months in Victoria and New South Wales in the second year of the pandemic. Within these quasi-experimental settings, our empirical approach was to first use monthly data at the State-level and estimate birth rate deviations from secular trends for the months affected by COVID-19 policies. We also estimate separate models to examine variations in births across regional areas with different compositions of Indigenous population, unemployment, low-income, and non-English speaking residents. Our findings reveal a nationwide fertility increase in 2021, but Victoria exhibited slower growth, especially in areas with higher unemployment, lower income, and more non-English speaking residents. In 2022, we find evidence of a gradual return of birth rates to pre-pandemic trends, though this is mainly concentrated in the major cities. While the second-year lockdowns had limited impacts, language-diverse areas still mostly experienced lower rates of growth in birth rates.
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Affiliation(s)
- Irma Mooi-Reci
- School of Social and Political Sciences, Level 5, John Medley Bldg, The University of Melbourne, Victoria, 3010, Australia
| | - Mark Wooden
- Melbourne Institute: Applied Economic & Social Research, University of Melbourne, Victoria, 3010, Australia
| | - Federico Zilio
- Melbourne Institute: Applied Economic & Social Research, University of Melbourne, Victoria, 3010, Australia
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Vittucci AC, Antilici L, Russo C, Musolino AMC, Cristaldi S, Cutrera R, Persia S, Di Maio CV, Raponi M, Perno CF, Villani A. Respiratory syncytial virus: can we still believe that after pandemic bronchiolitis is not a critical issue for public health? Eur J Pediatr 2023; 182:5303-5313. [PMID: 37728752 PMCID: PMC10746572 DOI: 10.1007/s00431-023-05201-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infection among infants and young children, resulting in annual epidemics worldwide. Since the beginning of the COVID-19 pandemic, non-pharmacological interventions were applied, interfering with the circulation of most respiratory viruses, including RSV. The aim of this study is to analyze the RSV infection trend among hospitalized infants during the actual epidemic season (2022-2023) in comparison with the last pre-pandemic season (2018-2019), in order to outline whether significant differences emerge due to COVID-19 pandemia. We retrospectively reviewed medical data on infants hospitalized at the Bambino Gesù Children's Hospital with diagnosis of bronchiolitis in the current epidemic season and in the last pre-pandemic season, 2018-2019. RSV remains the main etiological agent of bronchiolitis in terms of frequency and severity of infections in the ongoing epidemic season. The first RSV case of the 2022-2023 season was detected at week 42 vs week 47 in the 2018-2019 season. The length of epidemic season was of 17 weeks in 2022-2023 vs 18 weeks in 2018-2019. Comparing the two seasons, age at admission was significantly higher in the current season (median age 2022-2023 65 days vs median age 2018-2019 58 days), but the disease severity was similar. Conclusions: The 2022-2023 bronchiolitis season in Italy started earlier than the usual pre-pandemic seasons but seasonality pattern may be going back to the pre-pandemic one. This season was not more severe than the previous ones. The impact of RSV disease on health care systems and costs remains a critical issue. What is Known: • RSV is one of the major leading causes of hospitalization among children aged less than 3 months. SarsCOV2 pandemic interfered with the seasonal circulation of most respiratory viruses, Including RSV. What is New: • The 2022-2023 bronchiolitis season in Italy started and peaked earlier than the usual pre-pandemic seasons but seasonality pattern may be realigning to the pre-pandemic one. The impact of RSV disease on health care systems and costs is concerning.
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Affiliation(s)
- Anna Chiara Vittucci
- Emergency, Acceptance and General Pediatrics Department, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4-00165, Rome, Italy.
| | - Livia Antilici
- Emergency, Acceptance and General Pediatrics Department, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4-00165, Rome, Italy
| | - Cristina Russo
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Childrens Hospital, IRCCS, Rome, Italy
| | - Anna Maria Caterina Musolino
- Emergency, Acceptance and General Pediatrics Department, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4-00165, Rome, Italy
| | - Sebastian Cristaldi
- Emergency, Acceptance and General Pediatrics Department, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4-00165, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sabrina Persia
- Emergency, Acceptance and General Pediatrics Department, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4-00165, Rome, Italy
| | - Chiara Velia Di Maio
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Childrens Hospital, IRCCS, Rome, Italy
| | | | - Carlo Federico Perno
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Childrens Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Emergency, Acceptance and General Pediatrics Department, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4-00165, Rome, Italy
- System Medicine Department, Tor Vergata University of Rome, Rome, Italy
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7
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Golovina K, Nenko I, Marcinkowska UM. Childcare burden and changes in fertility desires of mothers during the COVID-19 pandemic. Front Psychol 2023; 14:1243907. [PMID: 38106382 PMCID: PMC10723901 DOI: 10.3389/fpsyg.2023.1243907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/26/2023] [Indexed: 12/19/2023] Open
Abstract
Objectives Previous studies have documented a decline in fertility desires and intentions following the COVID-19 outbreak, but the reasons for this decline are not well understood. This study examined whether childcare burden on mothers during the lockdown and quarantines, COVID-related stress, and COVID exposure were associated with a change in the desired number of children. Methods The survey was conducted online, in Poland from April to July 2021 on a sample of 622 non-pregnant mothers without diagnosed infertility. Results Associations were observed between childcare responsibilities during the quarantine and fertility desires: mothers who solely or mainly took care of their children during the quarantine(s) were more likely to decrease their desired number of children ([adjusted] aOR = 1.91, 95% CI = 1.16-3.15). Mothers with higher levels of COVID-related stress (aOR = 1.81, 95% CI = 1.48-2.22) and a greater COVID exposure index (aOR = 1.39, 95% CI = 1.12-1.72) were more likely to decrease their fertility desires. Conclusion Higher childcare burden during quarantines was related to a lower desired number of children among mothers. Both greater COVID-related stress and COVID exposure were associated with fertility desires, regardless of childcare responsibilities during the pandemic.
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Affiliation(s)
- Kateryna Golovina
- Helsinki Collegium for Advanced Studies, University of Helsinki, Helsinki, Finland
| | - Ilona Nenko
- Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
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8
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Baxter AJ, Geary RS, Dema E, Bosó Pérez R, Riddell J, Willis M, Conolly A, Oakley LL, Copas AJ, Gibbs J, Bonell C, Sonnenberg P, Mercer CH, Clifton S, Field N, Mitchell K. Contraceptive use and pregnancy planning in Britain during the first year of the COVID-19 pandemic: findings from a large, quasi-representative survey (Natsal-COVID). BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:260-273. [PMID: 36958823 PMCID: PMC10579517 DOI: 10.1136/bmjsrh-2022-201763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/12/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Contraceptive services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic. METHODS Natsal-COVID Wave 2 surveyed 6658 adults aged 18-59 years between March and April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18-44 years, described as female at birth. We analysed contraception use, contraceptive switching due to the pandemic, contraceptive service access, and pregnancy plannedness. RESULTS Of 1488 participants, 1619 were at risk of unplanned pregnancy, of whom 54.1% (51.0%-57.1%) reported routinely using effective contraception in the past year. Among all participants, 14.3% (12.5%-16.3%) reported switching or stopping contraception due to the pandemic. 3.2% (2.0%-5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%-5.9%) stopped. 29.3% (26.9%-31.8%) of at-risk participants reported seeking contraceptive services, of whom 16.4% (13.0%-20.4%) reported difficulty accessing services. Clinic closures and cancelled appointments were commonly reported pandemic-related reasons for difficulty accessing services. This unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%-11.1%) scored as 'unplanned'; less planning was associated with younger age, lower social grade and unemployment. CONCLUSIONS Just under a third of participants sought contraceptive services during the pandemic and most were successful, indicating resilience and adaptability of service delivery. However, one in six reported an unmet need due to the pandemic. COVID-induced inequalities in service access potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond.
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Affiliation(s)
- Andrew J Baxter
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rebecca S Geary
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Emily Dema
- Institute for Global Health, University College London, London, UK
| | - Raquel Bosó Pérez
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Julie Riddell
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Malachi Willis
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Anne Conolly
- Institute for Global Health, University College London, London, UK
- NatCen Social Research, London, UK
| | - Laura L Oakley
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew J Copas
- Institute for Global Health, University College London, London, UK
| | - Jo Gibbs
- Institute for Global Health, University College London, London, UK
| | | | - Pam Sonnenberg
- Institute for Global Health, University College London, London, UK
| | | | - Soazig Clifton
- Institute for Global Health, University College London, London, UK
- NatCen Social Research, London, UK
| | - Nigel Field
- Institute for Global Health, University College London, London, UK
| | - Kirsten Mitchell
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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9
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Moreno-Louzada L, Menezes-Filho N. The relationship between staying at home during the pandemic and the number of conceptions: A national panel data analysis. PLoS One 2023; 18:e0289604. [PMID: 37566617 PMCID: PMC10420359 DOI: 10.1371/journal.pone.0289604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
hether the COVID-19 pandemic has changed fertility patterns is still an open question, as social isolation for long periods can impact the number of conceptions in many ways. We combine administrative data on all recent births in Brazil with daily data on individual location to estimate the relationship between the share of individuals staying close to their homes in each week and the number of conceptions in that same week, comparing municipalities with different social isolation patterns during the first semester of 2020. We find that conceptions unequivocally decline when social isolation increases. The effect is stronger for women who are between 21 and 25 years old and more educated, as well as for richer, larger, and more urban municipalities. COVID-19 is likely to change fertility across countries depending on the behavior of the population and on the lock-down measures implemented to fight the pandemic.
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10
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Alaimo LS, Nosova B, Salvati L. Did COVID-19 enlarge spatial disparities in population dynamics? A comparative, multivariate approach for Italy. QUALITY & QUANTITY 2023:1-30. [PMID: 37359970 PMCID: PMC10235851 DOI: 10.1007/s11135-023-01686-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/28/2023]
Abstract
A short-term issue that has been occasionally investigated in the current literature is if (and, eventually, how) population dynamics (directly or indirectly) driven by COVID-19 pandemic have contributed to enlarge regional divides in specific demographic processes and dimensions. To verify this assumption, our study run an exploratory multivariate analysis of ten indicators representative of different demographic phenomena (fertility, mortality, nuptiality, internal and international migration) and the related population outcomes (natural balance, migration balance, total growth). We developed a descriptive analysis of the statistical distribution of the ten demographic indicators using eight metrics that assess formation (and consolidation) of spatial divides, controlling for shifts over time in both central tendency, dispersion, and distributional shape regimes. All indicators were made available over 20 years (2002-2021) at a relatively detailed spatial scale (107 NUTS-3 provinces) in Italy. COVID-19 pandemic exerted an impact on Italian population because of intrinsic (e.g. a particularly older population age structure compared with other advanced economies) and extrinsic (e.g. the early start of the pandemic spread compared with the neighboring European countries) factors. For such reasons, Italy may represent a sort of 'worst' demographic scenario for other countries affected by COVID-19 and the results of this empirical study can be informative when delineating policy measures (with both economic and social impact) able to mitigate the effect of pandemics on demographic balance and improve the adaptation capacity of local societies to future pandemic's crises.
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Affiliation(s)
| | - Bogdana Nosova
- Department of Social Communications, Institute of Giornalism, Taras Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - Luca Salvati
- Department of Methods and Models for Economics, Territory and Finance, Faculty of Economics, Sapienza University of Rome, Via del Castro Laurenziano 9, 00161 Rome, Italy
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11
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Adelman S, Charifson M, Seok E, Mehta-Lee SS, Brubaker SG, Liu M, Kahn LG. State-specific fertility rate changes across the USA following the first two waves of COVID-19. Hum Reprod 2023; 38:1202-1212. [PMID: 37038265 PMCID: PMC10233281 DOI: 10.1093/humrep/dead055] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/02/2023] [Indexed: 04/12/2023] Open
Abstract
STUDY QUESTION How did the first two coronavirus disease 2019 (COVID-19) waves affect fertility rates in the USA? SUMMARY ANSWER States differed widely in how their fertility rates changed following the COVID-19 outbreak and these changes were influenced more by state-level economic, racial, political, and social factors than by COVID-19 wave severity. WHAT IS KNOWN ALREADY The outbreak of the COVID-19 pandemic contributed to already declining fertility rates in the USA, but not equally across states. Identifying drivers of differential changes in fertility rates can help explain variations in demographic shifts across states in the USA and motivate policies that support families in general, not only during crises. STUDY DESIGN, SIZE, DURATION This is an ecological study using state-level data from 50 US states and the District of Columbia (n = 51). The study period extends from 2020 to 2021 with historical data from 2016 to 2019. We identified Wave 1 as the first apex for each state after February 2020 and Wave 2 as the second apex, during Fall/Winter 2020-2021. PARTICIPANTS/MATERIALS, SETTING, METHODS State-level COVID-19 wave severity, defined as case acceleration during each 3-month COVID-19 wave (cases/100 000 population/month), was derived from 7-day weekly moving average COVID-19 case rates from the US Centers for Disease Control and Prevention (CDC). State-level fertility rate changes (change in average monthly fertility rate/100 000 women of reproductive age (WRA)/year) were derived from the CDC Bureau of Vital Statistics and from 2020 US Census and University of Virginia 2021 population estimates 9 months after each COVID-19 wave. We performed univariate analyses to describe national and state-level fertility rate changes following each wave, and simple and multivariable linear regression analyses to assess the relation of COVID-19 wave severity and other state-level characteristics with fertility rate changes. MAIN RESULTS AND THE ROLE OF CHANCE Nationwide, fertility dropped by 17.5 births/month/100 000 WRA/year following Wave 1 and 9.2 births/month/100 000 WRA/year following Wave 2. The declines following Wave 1 were largest among majority-Democrat, more non-White states where people practiced greater social distancing. Greater COVID-19 wave severity was associated with steeper fertility rate decline post-Wave 1 in simple regression, but the association was attenuated when adjusted for other covariates. Adjusting for the economic impact of the pandemic (hypothesized mediator) also attenuated the effect. There was no relation between COVID-19 wave severity and fertility rate change following Wave 2. LIMITATIONS, REASONS FOR CAUTION Our study harnesses state-level data so individual-level conclusions cannot be inferred. There may be residual confounding in our multivariable regression and we were underpowered to detect some effects. WIDER IMPLICATIONS OF THE FINDINGS The COVID-19 pandemic initially impacted the national fertility rate but, overall, the fertility rate rebounded to the pre-pandemic level following Wave 2. Consistent with prior literature, COVID-19 wave severity did not appear to predict fertility rate change. Economic, racial, political, and social factors influenced state-specific fertility rates during the pandemic more than the severity of the outbreak alone. Future studies in other countries should also consider whether these factors account for internal heterogeneity when examining the impact of the COVID-19 pandemic and other crises on fertility. STUDY FUNDING/COMPETING INTEREST(S) L.G.K. received funding from the National Institute of Environmental Health Sciences (R00ES030403), M.C. from the National Science Foundation Graduate Research Fellowship Program (20-A0-00-1005789), and M.L. and E.S. from the National Institute of Environmental Health Sciences (R01ES032808). None of the authors have competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Sarah Adelman
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| | - Mia Charifson
- Vilcek Institute of Biomedical Graduate Sciences, New York University Grossman School of Medicine, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Eunsil Seok
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Shilpi S Mehta-Lee
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sara G Brubaker
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Mengling Liu
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Linda G Kahn
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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12
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Muacevic A, Adler JR, Petrakos G, Panagopoulos P, Kornarou E, Barbouni A, Antonakopoulos N, Tigka M, Lykeridou A, Vrachnis N. Tracing Time Trends of Births in Greece. Cureus 2023; 15:e34040. [PMID: 36814739 PMCID: PMC9940775 DOI: 10.7759/cureus.34040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2023] [Indexed: 01/22/2023] Open
Abstract
Introduction The aim of this study was to comprehensively investigate and present time trends in births in Greece over the last seven decades. Methods Data on live births were derived from the Hellenic Statistical Authority, covering a 72-year period from 1950 to 2021. Trends in the number of births were assessed using joinpoint regression analysis. The annual percentage change (APC) and the average annual percent change (AAPC) were calculated with a 95% confidence interval (95% CI) and level of statistical significance p<0.05. Results The overall trend during 1950-2021 was clearly downward (AAPC = -0.9, 95% CI: -1.2 to -0.7). Over the first three decades, births fluctuated to a record high of 162,839 in 1967, with an overall slight downward trend (1950-1981: APC = -0.2, 95% CI: -0.4 to -0.1, p<0.001). During the 1980 decade, the trend was sharply downward (1981-1988: APC = -4.7, 95% CI: -6.2 to -3.2, p<0.001), followed by a stabilization in the 1990s (1988-2001: APC = -0.1, 95% CI: -0.7 to 0.4, p=0.586). The first decade of the 21st century was the only period during the last seven decades with an increasing trend in births in the Greek population (2001-2008: APC = 1.9, 95% CI: 0.3 to 3.5, p = 0.021), but it was followed by plummeting trends during the recent years (2008-2021: APC = -2.7, 95% CI: -3.2 to -2.3, p<0.001), leading to the historic low of 83,756 births in 2019. Conclusion The time trend analysis of births in Greece indicated a dramatic plummet in natality in Greece, predominantly attributed to the large decline in births in the 1980s, which could not be reversed in the 1990s and 2000s. The recent decrease in births was associated with the financial recession and has put the Greek population in a disastrous low-fertility spiral.
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13
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Iacobucci G. Sixty seconds on . . . pandemic babies. BMJ 2022; 379:o2489. [PMID: 36252962 DOI: 10.1136/bmj.o2489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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14
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De Geyter C. Live birth numbers undulate as crises come and go. Hum Reprod 2022; 37:2728-2729. [PMID: 36228657 PMCID: PMC9619654 DOI: 10.1093/humrep/deac232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Indexed: 12/14/2022] Open
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15
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Rodriguez K, Nudelman MJ, Jegatheesan P, Huang A, Devarajan K, Haas JE, Cervantes R, Falbo K, Narasimhan SR, Cormier M, Stewart MB, Patel R, Govindaswami B. Are preterm birth and very low birth weight rates altered in the early COVID (2020) SARS-CoV-2 era? Front Pediatr 2022; 10:1093371. [PMID: 36699310 PMCID: PMC9869366 DOI: 10.3389/fped.2022.1093371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE We evaluated the prevalence of preterm birth (PTB) and very low birth weight (VLBW) during Jan-Dec 2,020 (early COVID era) at 5 hospitals (2 in West Virginia, 3 in California) compared to Jan 2017-Dec 2019 (pre-COVID) inclusive of 2 regional perinatal centers (1 in Huntington, WV and 1 in San Jose, CA) and 3 community hospitals (1 each in Cabell, Los Angeles and Santa Clara counties). DESIGN/METHODS We examined PTB and VLBW rates of live births at 5 US hospitals from Jan 2017-Dec 2020. We compared PTB and VLBW rates in 2020 to 2017-2019 using Poisson regression and rate ratio with a 95% confidence interval. We stratified live births by gestational age (GA) (<37, 33-36, and <33 weeks) and birth weight (≤1,500 g, >1,001 g to ≤1,500 g, ≤1,000 g). We examined PTB rates at 4 of the hospitals during Jan-Dec 2020 and compared them to the prior period of Jan 2017-Dec 2019 using Statistical Process Control (SPC) for quarterly data. RESULTS We examined PTB and VLBW rates in 34,599 consecutive live births born Jan 2017-Dec 2019 to rates of 9,691 consecutive live births in 2020. There was no significant change in PTB (<37 weeks GA) rate, 10.6% in 2017-2019 vs. 11.0% in 2020 (p = 0.222). Additionally, there was no significant change when comparing VLBW rates in 2017-2019 to 2020, 1.4% in 2017-2019 vs. 1.5% in 2020 (p = 0.832). CONCLUSION We found no significant change in the rates of PTB or VLBW when combining the live birth data of 5 US hospitals in 3 different counties.
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Affiliation(s)
- Kayla Rodriguez
- Neonatology/Pediatrics, Mountain Health Network, Marshall University, Huntington, WV, United States.,Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, United States
| | - Matthew J Nudelman
- Neonatology/Pediatrics, Mountain Health Network, Marshall University, Huntington, WV, United States.,Neonatology/Pediatrics, Santa Clara Valley Healthcare, San Jose, CA, United States
| | - Priya Jegatheesan
- Neonatology/Pediatrics, Santa Clara Valley Healthcare, San Jose, CA, United States
| | - Angela Huang
- Neonatology/Pediatrics, Santa Clara Valley Healthcare, San Jose, CA, United States
| | - Kamakshi Devarajan
- Neonatology/Pediatrics, St. Francis Medical Center, Lynwood, CA, United States.,Utilization Managment and Population Health, Silversummit Health Plan, Nevada Subsidiary of Centene Corporation, Las Vegas, Nevada, MO, United States
| | - Jessica E Haas
- Neonatology/Pediatrics, Mountain Health Network, Marshall University, Huntington, WV, United States
| | - Rosemarie Cervantes
- Neonatology/Pediatrics, St. Francis Medical Center, Lynwood, CA, United States
| | - Kelle Falbo
- Neonatology/Pediatrics, St. Francis Medical Center, Lynwood, CA, United States
| | | | - Machelnil Cormier
- Neonatology/Pediatrics, Santa Clara Valley Healthcare, San Jose, CA, United States
| | - Mary Beth Stewart
- Neonatology/Pediatrics, Mountain Health Network, Marshall University, Huntington, WV, United States
| | - Rupalee Patel
- Neonatology/Pediatrics, Santa Clara Valley Healthcare, San Jose, CA, United States
| | - Balaji Govindaswami
- Neonatology/Pediatrics, Mountain Health Network, Marshall University, Huntington, WV, United States.,Neonatology/Pediatrics, Santa Clara Valley Healthcare, San Jose, CA, United States.,VMC Foundation, San Jose, CA, United States
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