key: cord-0858354-de8t9gki
authors: Goyal, Manu; Singh, Pratibha; Singh, Kuldeep; Shekhar, Shashank; Agrawal, Neha; Misra, Sanjeev
title: The effect of the COVID‐19 pandemic on maternal health due to delay in seeking health care: Experience from a tertiary center
date: 2020-12-21
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13457
sha: 1aa9b4c244af4bc221ed303b8dd516f6896c2b9b
doc_id: 858354
cord_uid: de8t9gki

OBJECTIVE: To assess the effects of the COVID‐19 pandemic on obstetric care and outcomes. METHODS: A prospective observational single‐center study was performed, including all antenatal and parturient women admitted from April to August, 2020. Data were collected regarding number of admissions, deliveries, antenatal visits, reason for inaccessibility of health care, and complications during pregnancy, and compared with data from the pre‐COVID period of October 2019 to February 2020. RESULTS: There was a reduction of 45.1% in institutional deliveries (P < 0.001), a percentage point increase of 7.2 in high‐risk pregnancy, and 2.5‐fold rise in admission to the intensive care unit of pregnant women during the pandemic. One‐third of women had inadequate antenatal visits. The main reason for delayed health‐seeking was lockdown and fear of contracting infection, resulting in 44.7% of pregnancies with complications. Thirty‐two symptomatic women who tested positive for COVID‐19 were managed at the center with good maternal and fetal outcomes. CONCLUSION: Although COVID‐19 does not directly affect pregnancy outcomes, it has indirect adverse effects on maternal and child health. Emergency obstetric and antenatal care are essential services to be continued with awareness of people while maintaining social distancing and personal hygiene.

The COVID-19 pandemic has grossly affected the lives of people since its onset in December 2019 across the world. 1 The pandemic resulted in major changes in government policies, including the healthcare system. There have been curfew restrictions in hotspot areas, and certain places have become containment zones from where a large cluster tested positive for coronavirus. This has also led to poor or inadequate delivery of many services, especially the health services. This mass restriction of activities was intended to prevent community spread of the infection and to allow for preparedness of the medical services for the pandemic. On the other hand, the routine healthcare system was disrupted and people faced problems when seeking medical advice. Although COVID-19 disease itself does not cause increased maternal mortality compared to the general population directly, unsupervised pregnancies and the absence of routine antenatal visits may have indirect adverse effects on maternal health. 2 During epidemics in the past, health systems were crippled to provide routine services to a large extent due to the sudden increase in demand and the redirection of the workforce towards the epidemics.

Hence, the utilization of routine health services significantly reduces during every outbreak. 3 As has already been said by WHO, "People, efforts, and medical supplies all shift to respond to the emergency. This may lead to the neglect of routine essential health services. People with health problems unrelated to the epidemic find it harder to get access to health care services". 4 During the Ebola virus outbreak in West Africa in 2014, the indirect effects of the epidemic on maternal health were more severe than the outbreak itself. 5 It was estimated that, during this outbreak, there was a decrease of 22 percentage points in antenatal care coverage, of 8 percentage.

points in in-facility delivery, and of 13 percentage points in postnatal care. 6 This decrease was mainly due to fear of contracting the disease from medical staff and other patients, loss of faith in the health system, and the exact source of the disease being unknown. 7 A similar reduction in healthcare utilization was seen during the severe acute respiratory syndrome (SARS) epidemic in 2003. In Taiwan, ambulatory care decreased by 23.9% and inpatient care decreased by 35.2%. 8 The current coronavirus disease (SARS-CoV-2 infection) was declared a global pandemic by WHO on March 11, March 2020. 9 Social restrictions and isolation challenged the care of pregnant women. Telehealth was introduced to tide over the situation to some extent. Certain medical conditions can be diagnosed only on physical evaluation of the patient. In the absence of routine care, high-risk factors in pregnant women are missed, which can lead to dreaded complications. This pandemic has resulted in the non-accessibility of antenatal women to care providers in an emergency.

These are major concerns in the utilization of health services for all.

Taking lessons from past epidemics, the Ministry of Health and Family Welfare, India (MOHFW) and FOGSI (Federation of Obstetricians & Gynecologists of India) declared pregnant women to be a high-risk group and mandated guidelines to provide essential maternal health services as well as to patients with suspected or confirmed COVID-19. 10 Guidelines have been laid down for modified prenatal care. [11] [12] [13] [14] In low-and middle-income countries such as India, the impact of containment and other policies on maternal health will be more devastating. Even in the days before the pandemic, timely maternal healthcare services were unavailable or inaccessible for millions of women in low-resource settings. The restrictions on travel and limited health facilities with infection-control preparedness have further exacerbated the negative impact on women's health. There has been a drastic decline in the number of institutional deliveries, which ultimately deteriorates maternal and child care. The side effects of lockdown on maternal health have so far been largely unexplored. Therefore, the aim of the present study was to assess the indirect effect of the COVID-19 pandemic on the health of pregnant women and fetal-maternal outcomes.

The present study was conducted in the Department of Obstetrics and Gynecology at All India Institute of Medical Sciences, Jodhpur for a period of 5 months from April 1, 2020, to August 31, 2020. It was a prospective observational single-center study that included all pregnant women admitted during the study period. The study was approved by the Institutional Ethics Committee and informed consent was obtained from the study participants. The number of admissions, deliveries, high-risk women, and referrals was assessed. These data were compared with those from routine pre-COVID-19 days, from October 1, 2019, to February 29, 2020, just before the pandemic (Table 1) . March 2020 was not included in the analysis as the lockdown started in the middle of the month and these data were inconclusive. During the pandemic, the institute provided antenatal services through telemedicine, and physical visits were scheduled as per regional guidelines for low-risk women. High-risk women were called more frequently as needed. Moreover, emergency services were continued and all patients were treated, whether they were registered or not. Any delays in routine antenatal checkup and reasons for the delay were noted in all pregnant or delivered women during the COVID-19 period. The effect of delay in seeking health care on maternal complications was assessed.

Data entry was carried out using MS Excel Software and analyzed using SPSS version 21 (SPSS Inc.). The descriptive and analytical statistics are presented in frequency tables and graphs. The categorical variables were briefed as numbers and percentages. The Student ttest was used to analyze the demographic data. P < 0.05 was considered statistically significant. 

Though COVID-19 has not directly affected maternal and fetal outcomes, the present study shows that COVID-19 has definitely affected pregnancy outcomes indirectly. It was found that there was a drastic fall in the number of institutional deliveries, especially during the period of strict lockdown. The women preferred home deliveries or deliveries at a nearby health facility, due to either inaccessibility, When examined on a larger scale, such a major fall has challenged international safe motherhood programs. The reduced number of antenatal visits and institutional deliveries will lead to a marked increase in pregnancies with complications and the need for intensive care. The main reason for admission to the ICU in the present study was an increase in morbidities such as multiorgan failure and acute renal failure. An increase in the maternal mortality rate was also observed. Thus, it appears that the COVID-19 pandemic will indirectly cause a big setback to the international efforts of achieving sustainable development goals.

In the study by Davis et al, 15 it was found that women are preferring home deliveries instead of institutional deliveries due to the fear of contagion from institutes. However, this should only be accepted in women who are considered low risk. The main reasons behind the home deliveries was the patients avoiding visiting hospitals until an emergency due to transportation issues and resistance to approaching care providers.

One-third of women (32.5%) have avoided routine visits, considering pregnancy to be normal physiology and feeling safe at home.

The reason for the delay in health-seeking was the strict lockdown The strength of the present study is that it was prospective in nature and all the participants were followed up until delivery without any recall bias. At the same time, some limitations of the study include it being a single-center study at a tertiary hospital so generalizability cannot be ensured. Second, the women who were admitted to the institute were analyzed, while those coming to the outpatient department were not included. Lastly, the small sample size and TA B L E 3 observational nature of the study affected the detailed analysis of other independent predictors of patient delay. Large multicentric studies and worldwide surveys are needed to confirm these findings and better preparedness of obstetrics.

As in other pandemics, the healthcare system faces a great challenge during the COVID-19 pandemic, showing its indirect effects on the vulnerable antenatal group and an increase in pregnancy-related complications. Along with healthcare services, there is the need to educate patients about the importance of regular visits, precautions such as physical distancing, wearing masks, and personal hygiene. Leaving the home should be avoided but not at the cost of compromising health.

The authors have no conflicts of interest. 

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