A new review has revealed that pregnancy outcomes for women and babies worldwide worsened during the COVID-19 pandemic.
Pooled data from the review of 40 studies representing 17 countries showed stillbirth and maternal mortality rates increased by approximately one-third during the COVID-19 pandemic. Women requiring surgery for ectopic pregnancies also increased almost six-fold during the pandemic across all studies and revealed that mental health outcomes worsened during the pandemic, including increases in postnatal depression, maternal anxiety, or both.
The review, which shows a disproportionate impact on low- and middle-income countries and highlights health disparities worldwide, has been published in The Lancet Global Health.
Maternal health
Studies from individual countries have suggested that the pandemic has affected rates of stillbirth and pre-term birth, noting that this could be a result of a reduction of healthcare-seeking behaviour due to fear of catching COVID-19, as well as reduced provision of maternity services.
The review included two studies that investigated the impact of the pandemic on maternal death rates, both from middle-income countries. The pooled analysis found that the risk of mothers dying during pregnancy or childbirth was increased by more than a third compared with before the pandemic.
Overall, outcomes were worse in low- and middle-income countries as compared to high-income countries and the researchers say immediate action is required to preserve safe maternity care worldwide, especially during the global emergency.
Professor Asma Khalil, lead author of the study, of St George’s University of London, said: “The COVID-19 pandemic has had a profound impact on health care systems around the world. Disruption to services, nationwide lockdowns, and fear of attending health care facilities means that the adverse effects of COVID-19 are expected to have health consequences that extend beyond the deaths and disease caused by the virus itself.
“It is clear from our study and others that the disruption caused by the pandemic has led to the avoidable deaths of both mothers and babies, especially in low- and middle-income countries. We urge policymakers and health care leaders to prioritise safe, accessible, and equitable maternity care within the strategic response to the pandemic and aftermath, to reduce adverse pregnancy outcomes worldwide.”
The review did not find any difference in overall rates of pre-term birth before and during the pandemic. However, pooled data from studies from high-income countries suggests that, in this setting, the odds of preterm birth were reduced by almost 10% during the pandemic.
The authors say the reduction appears to be driven by a drop in spontaneous pre-term birth, rather than those requiring medically indicated early induction of labour or caesarean section, which may be increased. This means it is more likely that changes in healthcare delivery and population behaviours are contributing factors, which may bring valuable lessons for understanding the mechanisms underlying preterm birth. The odds of having a pre-term birth in low- and middle-income countries were unchanged.
Ectopic pregnancies
The pooled data showed that the use of surgery for the treatment of ectopic pregnancies was almost six times higher during the pandemic compared with before, after accounting for the size of the included studies. However, if discovered early, ectopic pregnancies can be treated with medication, meaning the increase in surgeries may be an indication that more women delayed seeking care.
The variation in outcomes reported between different studies may be partially explained by inefficiencies in healthcare systems in the countries studied, the researchers found. Differences in pandemic mitigation responses between countries did not seem to affect the findings, however. The researchers say this suggests the increase in adverse pregnancy outcomes may be driven by pressures on healthcare systems caused by COVID-19 itself, rather than measures aimed at limiting the spread of the virus, such as lockdowns.
The researchers say their findings provide a clear indication that women and babies have experienced worse health outcomes during the pandemic, highlighting the need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises.
Dr Erkan Kalafat, a co-author of the study from Koc University, Turkey, said: “We have an unprecedented opportunity to learn from the experiences of the COVID-19 pandemic to plan for a future of inclusive and equitable maternity care worldwide. One such learning opportunity will be to investigate the mechanisms underlying the apparent reduction in pre-term births observed in high-income settings during the pandemic, with a view to identifying new preventative interventions that could potentially benefit all women worldwide.”
Although the study did not analyse the impact of COVID-19 infection during pregnancy, it provides the first global assessment of the collateral impact of the pandemic on antenatal, birth, and postnatal outcomes.
The authors note several limitations to their findings. Notably, the studies included in their analysis varied in the way pregnancy outcomes were defined and measured, which makes it difficult to compare results between studies. There were fewer studies from low- and middle-income settings, and this is concerning as the analysis shows substantial variation in outcomes between high- and low-income settings. The authors also note that they cannot exclude the risk of publication bias against studies reporting negative findings, although they did not find any evidence of bias when they tested for this.
