COVID-19 ‘led to rise in stillbirths, maternal deaths’

Immediate action is required to preserve safe maternity care worldwide, as the COVID-19 pandemic worsens global maternal and perinatal outcomes, especially in low- and middle- income countries (LMICs), a study warns.

The research, published in The Lancet Global Health (31 March), found increases in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression after analysing data on more than 6 million pregnancies. The review looked at 40 studies from 17 countries, conducted between 1 January, 2020 and 8 January, 2021.

Asma Khalil, a professor of obstetrics and maternal fetal medicine at St George’s University Hospital, London, and lead author of the study, said: “Disruption to services, nationwide lockdowns, and fear of attending healthcare facilities expose how the adverse effects of COVID-19 imply health consequences that extend beyond the deaths and disease caused by the virus itself.”

Although findings varied by country, analysis of pooled data showed that during the pandemic, and across all reviewed studies, stillbirth and maternal mortality rates increased by about one-third, while women requiring surgery for ectopic pregnancies grew almost six-fold.

“Disruption to services, nationwide lockdowns, and fear of attending healthcare facilities expose how the adverse effects of COVID-19 imply health consequences that extend beyond the deaths and disease caused by the virus itself,”

Asma Khalil, St George’s University Hospital, London

Outcomes were worse in LMICs than in high-income countries, researchers say.

Khalil told SciDev.Net by email that the increase in surgery for ectopic pregnancies was most likely caused by delayed consultations for pregnant women, who may be reluctant to attend hospital or have difficulties getting there amid COVID-19 restrictions. If discovered early, ectopic pregnancies can typically be treated with medication.

“The same relationship was not observed in other complications, such as gestational diabetes or pregnancy disorders linked to high blood pressure, as these are often not an acute or emergency condition like ectopic pregnancy which could lead to bleeding inside the pregnant woman’s abdomen and could potentially lead to death when it is not urgently treated,” Khalil added. “Gestational diabetes is often diagnosed in the later third of the pregnancy and is usually not dealt with as an emergency.”

The researchers also found a 10 per cent drop in preterm birth in high-income countries (HICs) – which was not seen in LMICs. This is likely caused by changes to behaviour during lockdowns resulting in a lower chance of women going into early or premature labour, Khalil explained.

However, mental health outcomes have worsened during the pandemic, the review found. Ten of the studies analysed included data on maternal mental health, of which six reported an increase in postnatal depression, maternal anxiety, or both.

Desirée Díaz Jiménez, a midwife with eight years of experience, who works in Malaga’s Maternal and Child Hospital, Spain, said: “In daily practice, we don’t see obstetric changes, but we do see repercussions at the psychological level. Mothers suffer a great emotional impact as during their stay at the hospital they may only be accompanied by one person, without family visits.”

Díaz Jiménez says the care provided today is somewhat different to that provided before the pandemic. Interactions between mothers and hospital staff are more distant, and if the pregnant woman has COVID-19, isolation may carry an element of social stigma.

Jogender Kumar and Praveen Kumar, from the Postgraduate Institute of Medical Education and Research in Chandigarh, India, welcome the way the study highlights disparities in healthcare within and across countries. However, they warn – in a comment article in the same edition of The Lancet Global Health – that most of the studies included in the review were single centre and may not be a true representation of community-level data.

Blanca Murillo Ortiz, from the clinical epidemiology research unit of the Mexican Social Security Institute, believes that the diversity of health systems and safety measures adopted to face the pandemic make the review analysis controversial.

The investigation also presented fewer studies on LMICs compared to HICs, with Latin America only represented by two reports, from Mexico and Brazil.

However, Murillo Ortiz agrees that “there is a strong need to prioritise the restructuring of maternity care”.

“Although new forms are being implemented, such as remote medical care, reduced hospital stays and outpatient monitoring, resources are needed to sustain these programmes,” she added.

Marta Cohen, paediatric and perinatal pathologist at the University of Sheffield, in northern England, remarks that the study presented in The Lancet Global Health did not address the possible COVID-19 vertical transmission from mother to foetus, or the infection of the placenta.

“Viral infections of the placenta do occur, and vertical transmission to the foetus has been demonstrated by many viruses, among them, the most common being DNA viruses, like Cytomegalovirus and Herpes Simplex Virus,” said Cohen, who did not take part in the study.

“Although during the first wave of SARS-CoV-2 infections there were little publications describing cases of vertical transmission from an infected pregnant woman to the foetus through the placenta, during the second wave affecting the United Kingdom, we have noted a surge in cases of stillbirth from women with the virus,” she added.

For Khalil, the study sends a clear message that decision makers should prioritise safe, accessible, and equitable maternity care within the strategic response to the pandemic, to reduce adverse pregnancy outcomes worldwide.

“They should also ensure that the public health message is to encourage pregnant women to seek help when needed and avoid unnecessary delay,” the researcher added.