key: cord-0741692-poa4cmwj authors: Kumar, Manisha; Puri, Manju; Yadav, Reena; Biswas, Ratna; Singh, Meenakshi; Chaudhary, Vidhi; Jaiswal, Nishtha; Meena, Deepika title: Stillbirths and the COVID‐19 pandemic: Looking beyond SARS‐CoV‐2 infection date: 2021-01-13 journal: Int J Gynaecol Obstet DOI: 10.1002/ijgo.13564 sha: d7fd875fb1bb85cf6f9b4287522d93821aee363a doc_id: 741692 cord_uid: poa4cmwj OBJECTIVE: To study the impact of the COVID‐19 outbreak and subsequent lockdown on the incidence, associated causes, and modifiable factors of stillbirth. METHODS: An analytical case‐control study was performed comparing stillbirths from March to September 2020 (cases) and March to September 2019 (controls) in a tertiary care center in India. Modifiable factors were observed as level‐I, level‐II, and level‐III delays. RESULTS: A significant difference in the rate of stillbirths was found among cases (37.4/1000) and controls (29.9/1000) (P = 0.045). Abruption in normotensive women was significantly higher in cases compared to controls (P = 0.03). Modifiable factors or preventable causes were noted in 76.1% of cases and 59.6% of controls; the difference was highly significant (P < 0.001, relative risk [RR] 1.8). Level‐II delays or delays in reaching the hospital for delivery due to lack of transport were observed in 12.7% of cases compared to none in controls (P < 0.006, RR 47.7). Level‐III delays or delays in providing care at the facility were observed in 31.3% of cases and 11.5% of controls (P < 0.001, RR 2.7). CONCLUSION: Although there was no difference in causes of stillbirth between cases and controls, level‐II and level‐III delays were significantly impacted by the pandemic, leading to a higher rate of preventable stillbirths in pregnant women not infected with COVID‐19. evant clinical findings and investigations were recorded in a stillbirth proforma especially designed for this purpose. The contributory cause of death was classified under the International Classification of Diseases [ICD]-10 PM system adopted by WHO in 2016 for use in classifying perinatal mortality. 5 The ICD PM classification system uses a layered approach to categorize perinatal mortality (including stillbirth) based on the time of death (antepartum or intrapartum), the fetal cause of death, and/or contributing maternal condition. The total number of live births were recorded each week from the existing healthcare facility registers (labor ward, admission discharge, and operation theatre registers). On a weekly basis, healthcare providers reviewed all stillbirths in the preceding week. One most relevant contributory maternal condition and one fetal cause were attributed to each stillbirth in these review meetings. Hypertensive disorder of pregnancy was taken as any rise in blood pressure of 140/90 mm Hg and above on two occasions, 4 hours apart. Pre-eclampsia was defined according to 2013 guidelines from the American College of Obstetricians and Gynecologists. 6 Fetal growth restriction (FGR) was diagnosed when the birth weight was less than the 10th centile for the gestational age according to the Intergrowth 21 chart. 7 Apart from direct causes, modifiable causes were also determined based on antenatal history and the details of the critical events related to stillbirth. The causes were divided into levels of delay: level I if the women arrived late due to not recognizing the need for care; level II due to failure to reach the hospital for treatment due to lack of transport facilities; and level III due to inadequate care by the provider. 8 Each cause was statistically analyzed using the Fisher exact test to calculate the P value and by paired t-test to compare the means. The relative risk (RR) of the significant variable was also calculated. Statistical analysis was performed using SPSS version 20, and P < 0.05 was considered significant. From March to September 2019, there were 6161 deliveries and 184 stillbirths (29.9/1000) whereas between March to September 2020, there were 3610 deliveries and 134 stillbirths (37.4/1000 deliveries). There was a significant increase in the stillbirth rate during the COVID-19 pandemic (P = 0.045) ( Figure 1 ). Most of the women in both cases and controls were aged 23-27 years and were primigravidae. No significant difference in maternal age (P = 0.121), gravidity (P = 0.288), and number of abortions (P = 0.193) were observed between the cases and controls (Table 1) . There were significantly fewer antenatal visits among cases compared to controls (P = 0.048). Significantly more women among the cases had a history of previous cesarean delivery (24/134, 17.9% vs 14/183, 7.7%, P = 0.014). vs 1/134, 0.5%) were performed in significantly more cases compared to controls (P < 0.001). There was no significant difference in the incidence of intrapartum (P = 0.105) or intramural stillbirth (P = 0.237) between the two groups. The causes associated with stillbirth are given in Table 3 respectively), but the difference was not statistically significant. Placental abruption was higher among the cases than the controls (16/134, 12% and 13/183, 7%, respectively) but the difference was not statistically significant (P = 0.169). However, the incidence of abruption in normotensive women was significantly higher in cases than in controls (P = 0.003). The relative risk of having abruption without hypertension was 3.69 among the cases. Regarding the fetal conditions leading to stillbirth, there was no statistical difference among the cases and controls (P > 0.05). Disorders related to fetal growth were the most common cause in both cases and controls (40/134, 29.9% and 59/183, 32.2%, respectively). All 134 mothers included in the analysis among the cases were screened for COVID-19 infection by reverse transcription polymerase chain reaction (RT PCR) at admission: only 2/134 (1.5%) of them were positive for COVID-19. In one case, there was severe acute respiratory distress leading to hypoxia and acidosis leading to intrauterine fetal death, and in the other, there was FGR and the mother had only a mild fever. The modifiable factors or preventable causes were noted in 102/134 (76.1%) cases and 109/183 (59.6%) controls. The difference was highly significant (P < 0.001) ( Table 4 ). The level-I delay or the delay in recognizing the need for care was the most common modifiable factor in both groups (43/134, 32.1% of the cases and 53/183, 29.1% of the controls); however, no antenatal check-up in the third trimester was observed in 29/134 (21.6%) cases compared to 11/183 (6%) controls (P < 0.001). There was no significant difference in the knowledge of danger signs between the cases and controls (P = 0.359). The delay in reaching the health facility (level-II delay) was seen only during the period of the pandemic in 17/134 (12.7%) cases. There were 3 (2.2%) deliveries at the entrance of the hospital due to the delay in arrival at the facility with resultant birth trauma to the baby. The delay in providing care at the facility by the provider (level-III delay) was observed in 42/134 (31.3%) cases, compared to 21/183 (11.5%) controls (P < 0.001). The women were referred to multiple hospitals in 15/134 (11.2%) cases compared to 3/183 (1.6%) controls (P = 0.002). Suboptimal care during labor in the initial weeks of the pandemic due to wearing of personal protective equipment (PPE), inability to listen to the fetal heart sounds while in PPE, and shortage of staff were the modifiable factors observed in significantly more cases compared to controls (P = 0.034). There was a delay in undertaking operative procedures due to the following of COVID-19 protocols in operation theatres with consequent stillbirth in 4/134 (3%) cases. The highest relative risk of having a stillbirth was due to delay in reaching the hospital (RR 47.70), delay in undertaking operative procedure (RR 12.20), and delay due to the patient being denied services and referred to more than one hospital before reaching our hospital (RR 6.80) ( Table 4 ). The present study highlights the impact of the COVID-19 outbreak on the rate of stillbirths and its related reasons by comparing and analyzing the data of stillbirths from a tertiary hospital between COVID-19 and pre-COVID-19 periods. The pandemic has resulted F I G U R E 1 The comparative study of total stillbirth and the details of modifiable causes in controls (2019) and cases (2020) in a significantly higher incidence of stillbirths not due to COVID-19 infection per se, but due to delays in care at all levels. The facilities were significantly impacted due to the lockdown and fear among both the pregnant women and healthcare providers during the pandemic resulting in many preventable stillbirths. The rates of stillbirth in low-income countries are tenfold higher compared to those in high-income countries. 9 It is important to understand how the pandemic has impacted the rates of stillbirth in high-and low-income countries. The WHO SEARO Neonatal-Perinatal Database Network study aims to establish a framework to assess the burden of stillbirths and neonatal deaths in low-income countries. The information generated regarding the modifiable factors contributing to stillbirths and neonatal deaths provides the decision-makers with guidance for changes in policy. The ICD-10 classification system was adopted for the classification of perinatal deaths (ICD-10 PM) to facilitate more accurate and uniform reporting of causes to enable comparison within and between settings. 6 The most common maternal cause contributing to stillbirth in previous studies has been hypertension, abruption, and diabetes in pregnancy. [10] [11] [12] Even during the pandemic, hypertension remained the most common cause of stillbirth. Among the fetal causes, disorders related to fetal growth were the most common. The causes of stillbirth were comparable in both groups, except there were significantly more cases of abruption in normotensive women during the pandemic compared to the previous year. This could possibly be related to nutritional deficiencies due to a lack of proper nutrition and supplements during the COVID-19 period. Values are given as number (percentage) unless otherwise specified. 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