Two studies find a sudden increase in the rate of stillbirth and neonatal death, which may, say their authors, be attributed to fewer hospitalisations during periods of lockdown.
Two recently published studies have reported a spike in stillbirths during the COVID-19 pandemic.(1,2) The first, a prospective study of more than 20,000 births in Nepal between 1 January and 30 May found that the rate of stillbirth increased from 14 per 1000 births before lockdown to 21 per 1000 births by the end of May, with the sharpest rise seen during the first four weeks of lockdown, when people were only allowed to leave home for food and medical care. The second paper, a retrospective analysis of deliveries in four tertiary care centres in India, found 49.8% fewer hospitalisations than in the same period the previous year. The number of referred obstetric emergencies also decreased by 66·4%. This study too showed a substantial rise in late fetal death and stillbirth, suggesting that the spike, according to the authors, ‘might be because of the delayed presentation of women requiring emergency obstetric care’.
A news comment on the two studies in the journal Nature
echoed that latter suggestion, saying that in some countries ‘pregnant women have received less care than they need’ because of lockdown restrictions and disruptions to health care.(3) ‘As a result,’ Nature
reports, ‘complications that can lead to stillbirths were probably missed.’ This is the interpretation too of the Indian researchers who of their spike in unattended deliveries write: ‘Immense media coverage along with stay-at-home and physical distancing advice from public health officials during the initial phase of the pandemic might have led to hospital-avoiding behaviour among pregnant women even before the implementation of the lockdown.’ They add that hospitals are now seen as ‘reservoirs’ of acute coronavirus, ‘and women are avoiding hospital even when they require tertiary-level care’.
The Nepal study, led from the University of Uppsala, Sweden, was nested within two large observational cohorts and provided data on 20,354 women who gave birth over five months covering 12·5 weeks before lockdown (1 January – 20 March) and 9·5 weeks during lockdown (21 March - 30 May). From the beginning to the end of this study period the mean weekly number of births decreased from 1261 births before lockdown to 651 births during lockdown - a reduction of 52·4%. It was also during this same period that still birth and neonatal mortality rates increased. Summarising implications in a ‘fragile health system’ like Nepal, the authors raise questions on policies regarding strict lockdowns in both low-income and middle-income countries during the COVID-19 outbreak. And even in high-income countries, as suggested by a short report of deliveries at a single hospital in London, the rate of stillbirth was found significantly higher during the pandemic period (9.31 per 1000 births) than during the pre-pandemic period (2.38 per 1000 births).(4) The overall numbers were small, but the UK authors nevertheless noted ‘a reluctance to go to hospital’ and ‘staff shortages’ as possible explanations.
1. Ashish KC, Guring R, Kinney MV, et al. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study. Lancet Global Health 2020; doi.org/10.1016/ S2214-109X(20)30345-4
2. Kumari V, Mehta K, Choudhary C. COVID-19 outbreak and decreased hospitalisation of pregnant women in labour. Lancet Glob Health 2020; doi.org/10.1016/ S2214-109X(20)30319-3
4. Khalil A, Van Dadelszen P, Draycott T, et al. Change in the incidence of stillbirth and preterm delivery during the COVID-19 pandemic. JAMA 2020; 324: 705-706. doi:10.1001/jama.2020.12746