key: cord-1033953-y2bsx8p2
authors: Speyer, Lydia Gabriela; Marryat, Louise; Auyeung, Bonnie
title: Impact of COVID-19 Public Health Safety Measures on Births in Scotland between March and May 2020
date: 2021-11-08
journal: Public Health
DOI: 10.1016/j.puhe.2021.10.013
sha: 7e83ae3264146a7dab3d077ea374fa067231cd4d
doc_id: 1033953
cord_uid: y2bsx8p2

Objective To combat the wide-spread transmission of COVID-19, many countries, including the United Kingdom, have imposed nationwide lockdowns. Little is known about how these public health safety measures affect pregnant mothers and their offspring. This study aimed to explore the impact of COVID-19 public health safety measures on births in Scotland. Study Design Cross-sectional study. Methods Using routinely collected health data on pregnancy and birth in Scotland, this study compares all births (N = 7342) between 24th of March and May 2020 to births in the same period in 2018 (N = 8323) to investigate the potential negative impact of public health safety measures introduced in Scotland in spring 2020. Birth outcomes were compared using Mann-Whitney-U tests and chi-square tests. Results Mothers giving birth during the pandemic tended to combine breastfeeding and formula-feeding rather than exclusively breastfeed or exclusively formula-feed, stayed in hospital for fewer days and more often had an epidural or a spinal anaesthetic compared to women giving birth in 2018. Conclusion Overall, results suggest little impact of public health safety measures on birth outcomes. Further research is needed to explore the longer-term impacts of being born in the pandemic on both maternal mental health and child development.

Coronavirus disease 2019 (COVID-19) is spreading rapidly around the globe after first identification in Wuhan, China, in December of 2019. In response, many countries, including the United Kingdom, have imposed nationwide lockdowns to combat the wide-spread transmission of COVID-19. In Scotland, the first Covid-19 cases were reported on March 1 st 2020 and a strict lockdown was put in place on March 24 th . These public health safety measures have had wide raging effects on everyone, but certain groups, such as pregnant women, might be particularly vulnerable to changes in social contacts and care provisions (1, 2) . Pregnant women were ordered to stay at home and self-isolate, partners were only allowed in hospital for the last stages of labour and were not allowed any visitors during their hospital stay. The lessening of parental choice, reduced social and formal support, and poorer maternal health compared to pre-pandemic life may have adverse effects on maternal and neonatal wellbeing.

Social-distancing has been shown to lead to an increase in mental health difficulties in the general population (1) and specifically in pregnant women (2, 3) . Compared to pre-COVID-19 pregnancy cohorts, women expecting a child during the COVID-19 pandemic in the UK suffer from substantially elevated psychological distress, with 57% reporting clinically relevant symptoms of anxiety, 37% reporting clinically relevant symptoms of depression, and 68%

reporting elevated pregnancy-related anxiety (3) . Public health safety measures have further led to a marked rise in domestic violence incidents in the United Kingdom as is reflected in a 49% increase in calls to the national domestic abuse helpline run by the charity Refuge (4), with pregnant women being of particularly high risk to experience violence also under normal circumstances (5) . As has been shown in pre-pandemic studies, domestic violence and elevated levels of depression or anxiety in pregnancy are risk factors for adverse maternal and neonatal outcomes (6) .

Taken together, these findings highlight the need to investigate the impact of nationwide public health safety measures on pregnancy and birth. This study gives some excluded from analyses as they tested positive for COVID-19 (198 women were tested). While sample sizes for COVID-19 positive women did not allow for further analyses, the data suggested that none of the women or babies had any particularly negative outcome. One important caveat that has to be kept in mind when interpreting the findings of this study is that the cohorts were recruited in two different years. Thus, they may have potentially been exposed to different non-Covid-19 related factors such as changes in health care provisions which could have influenced the results presented here.

A variety of maternal and infant outcomes were analysed: induction of labour (yes, no), mode of delivery (unassisted vaginal delivery, planned caesarean section, emergency caesarean section, other (e.g. use of forceps)), analgesia during labour (none, gas and air, opioids, epidural, spinal anaesthetic, general anaesthetics, other), birth outcome (livebirth, stillbirth, infant death), Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score (low = 0-3, moderately abnormal = 4-6, reassuring = 7-10 (7)) , age of gestation, birthweight, length of hospital stay, and feeding method on discharge (breastfeeding, formula, mixed feeding, other). Data were analysed using Mann-Whitney U tests for J o u r n a l P r e -p r o o f continuous outcomes and chi-square tests of independence for nominal outcomes. If the chisquare test was significant (α < 0.05), post-hoc tests (Fisher's exact tests) were conducted to examine all possible comparisons. These were additionally corrected for multiple comparisons using Bonferroni adjustment.

Descriptive Statistics are given in Table 1 Overall, results suggest that the public health safety measures implemented as a response to the COVID-19 pandemic have had relatively little impact on maternal and neonatal outcomes in Scotland. In line with findings from American hospitals (8), women giving birth in a Scottish hospital during the pandemic tended to leave maternity wards slightly faster than women who gave birth in the same months of 2018. This reduction in hospital stay duration is J o u r n a l P r e -p r o o f likely the result of policy modifications that were implemented to protect women as well as hospital staff against COVID-19 infections. Birth partners having to leave the hospital right after delivery and limited visitor numbers likely prompted women to go home as soon as possible. There has been some concern that reduction in hospital stays could lead to increases in the rate of adverse neonatal and maternal outcomes. However, in agreement with other studies looking at the impact of reducing hospital stay durations, our results do not support these concerns (8) .

Women giving birth during the COVID-19 pandemic in Scotland were further found to be more likely to combine breastfeeding with formula-feeding rather than to exclusively breastfeed or exclusively formula-feed. There has been some evidence from British hospitals that women giving birth during the pandemic were more likely to exclusively breastfeed than pre-pandemic cohorts (9) . This has been attributed to women having more time for themselves and their new-born as they had more help from their partners once home and fewer visitors.

There has, however, also been some evidence that women were less likely to continue breastfeeding long term due to a reduction of face-to-face services for breastfeeding support (10) . The increase in mixed feeding that was found in the current study could, however, also be the result of a more general change in feeding practises that is unrelated to the pandemic. For instance, it is possible that more hospitals are now encouraging mothers to supplement breastfeeding with bottle-feeding to counteract infant weight loss which otherwise puts a lot of pressure on women who may struggle with producing enough breastmilk to exclusively breastfeed. This is however purely speculative and further research is needed to investigate general trends in infant feeding practices.

Results further indicated that women giving birth between March and May 2020 more often had an epidural or received spinal anaesthetics than women giving birth in the same period in 2018. One potential reason for this finding is that birth partners were restricted to just J o u r n a l P r e -p r o o f 7 one person who often was only allowed into the labour ward once the expectant mum was already in active labour. This could have resulted in women having reduced pain tolerance in active labour as they were left to cope with the pain of early labour without a supportive birth partner present. Another potential reason for this finding is that during COVID-19, an increased number of consultants and anaesthetic staff were present to provide care for any women that may have presented with COVID-19. Thus, this could have made it easier for women to receive an epidural or spinal anaesthetic. However, it is also possible that epidurals and spinal anaesthetics are gaining in popularity independently of the COVID-19 pandemic.

In conclusion, findings of the current study suggest that public health safety measures implemented in Scotland as a response to the COVID-19 pandemic had limited impact on maternal and neonatal outcomes. While these findings are reassuring, future research is needed to gain better insights into the impact of COVID-19 and associated public health safety measures on maternal and child health.

J o u r n a l P r e -p r o o f 

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Mental health status of pregnant and breastfeeding women during the COVID-19 pandemic: A call for action

Elevated depression and anxiety among pregnant individuals during the COVID-19 pandemic

Domestic abuse and risks of harm within the home

Home Office preparedness for Covid-19 (Coronavirus): domestic abuse and risks of harm within the home -Home Affairs Committee -House of Commons

The prevalence of domestic violence in pregnant women

Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice

Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic

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Covid-19 lockdown on the experiences and feeding practices of new mothers in the UK: Preliminary data from the COVID-19 New Mum Study. Appetite

Relative Risk Ratio are given in comparison to the reference group, e.g., breastfed vs formula-fed and breastfed vs mixed with higher/lower ratios indicating that an outcome was more/less likely in the 2020 cohort than in the 2018 cohort, p-values are based on Mann-Whitney U tests for continuous variables and on chi-square tests for categorical variables.