Title: COVID-19 and maternal and perinatal outcomes
Abstract: We echo the call made by Barbara Chmielewska and colleagues1Chmielewska B Barratt I Townsend R et al.Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e759-e772Summary Full Text Full Text PDF PubMed Scopus (506) Google Scholar for better data to capture the effects of COVID-19 on maternal outcomes. Our own systematic review (PROSPERO CRD42020219889, in progress) specifically focuses on the amount of maternal mortality as measured by the maternal mortality ratio, and our findings so far concur with their conclusion of an increase, but we advise caution in the interpretation of this trend. In our review, we have been struck by the absence of specificity on population coverage in published papers, which has implications for understanding and responding to COVID-19. This fact is illustrated by Chmielewska and colleagues1Chmielewska B Barratt I Townsend R et al.Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e759-e772Summary Full Text Full Text PDF PubMed Scopus (506) Google Scholar who use two studies to conclude an increase, but do not comment on the sources for identifying the numbers of maternal deaths. One study uses Mexican National Registry data and should, in theory, capture all maternal deaths in Mexico.2Lumbreras-Marquez MI Campos-Zamora M Seifert SM et al.Excess maternal deaths associated with coronavirus disease 2019 (COVID-19) in Mexico.Obstet Gynecol. 2020; 136: 1114-1116Crossref PubMed Scopus (17) Google Scholar The second study relies on data from four tertiary hospitals in India.3Kumari V Mehta K Choudhary R COVID-19 outbreak and decreased hospitalisation of pregnant women in labour.Lancet Glob Health. 2020; 8: e1116-e1117Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar In this second study, the authors document a substantial decrease in pregnant women attending for delivery in their study facilities in the period after the emergence of COVID-19.3Kumari V Mehta K Choudhary R COVID-19 outbreak and decreased hospitalisation of pregnant women in labour.Lancet Glob Health. 2020; 8: e1116-e1117Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar This reduction suggests that women are seeking care at different facilities or delivering at home, and such a shift in service use will probably distort the comparison of the maternal mortality ratio before and during COVID-19. Indeed, the India study provides evidence that the COVID-19 pandemic has had a differential effect on women according to their obstetric risk, with a substantial 66·4% fall in emergency referrals.3Kumari V Mehta K Choudhary R COVID-19 outbreak and decreased hospitalisation of pregnant women in labour.Lancet Glob Health. 2020; 8: e1116-e1117Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar The observed change in institutional maternal mortality is reflecting this shifting casemix, but such a trend should not be extrapolated to the wider population where other factors affecting risk are at play, such as socioeconomic determinants. Only one part of the picture is being looked at when examining institutional data, which subsequently distorts actions to achieve a future of "radically inclusive and equitable maternity care".1Chmielewska B Barratt I Townsend R et al.Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e759-e772Summary Full Text Full Text PDF PubMed Scopus (506) Google Scholar Crucially, and as noted in the Comment4Kumar J Kumar P COVID-19 pandemic and health-care disruptions: count the most vulnerable.Lancet Glob Health. 2021; 9: e722-e723Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar accompanying the paper by Chmielewska and colleagues, community-based reporting of maternal deaths and births should be the ultimate goal if there is to be a full understanding of the societal effect and trends. Lessons from the rapid set-up of reporting systems for COVID-19 mortality in the community should inform progress on maternal death surveillance. In the immediate term, we call for the improved reporting of data used to calculate the maternal mortality ratio. Standardised reporting formats, such as the Strengthening the Reporting of Observational Studies in Epidemiology,5von Elm E Altman DG Egger M Pocock SJ Gøtzsche PC Vandenbroucke JP The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.Int J Surg. 2014; 12: 1495-1499Crossref PubMed Scopus (4964) Google Scholar would not only enhance the assessment of bias but also the value of these data in any action taken to reduce maternal deaths. We declare no competing interests. COVID-19 and maternal and perinatal outcomesThe International Stillbirth Alliance welcomes the systematic review by Barbara Chmielewska and colleagues (June, 2021),1 particularly its inclusion of stillbirths, because these are often missing from the global agenda. The 28% increased pooled odds in reported stillbirth during the COVID-19 pandemic is concerning. We wish to highlight some data limitations that will impede action to reduce these preventable deaths. Full-Text PDF Open AccessCOVID-19 outbreak and decreased hospitalisation of pregnant women in labourAt a tertiary health-care level in India, which is mainly provided by medical colleges and advanced medical research institutes, specialised consultative care is given to patients who are referred from primary and secondary medical care, along with general care for the local community.1 The maternal mortality ratio in India has reduced by 78%, from 556 per 100 000 livebirths in 1990 to 122 per 100 000 livebirths in 2015–17, mainly because of an increase in institutional deliveries (from 18% in 2005 to 79% in 2016) and an effective referral system for emergency obstetric care. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomesWe commend Barbara Chmielewska and colleagues1 for undertaking a timely and comprehensive systematic review on a topic of pivotal global health importance. The increase in maternal mortality and stillbirths during the COVID-19 pandemic, particularly in low-resource settings, is of considerable concern. Although a substantial number of studies were collated, many have a substantial risk of bias. For example, of the 18 included studies assessing the link between the pandemic and preterm birth, only two had a quasi-experimental design, many did not have detailed methods, few adjusted for potential confounding factors, and only three included population-level data. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomes – Authors' replyWe thank all correspondents for their interest in our report.1 A common point is the need for better quality studies in this area, which we wholeheartedly echo. Quality and consistency in reporting, particularly of key outcomes such as maternal death, stillbirth, and preterm birth, are essential if we are to tackle these scourges of maternity care. Full-Text PDF Open AccessCOVID-19 and maternal and perinatal outcomesIn their systematic review and meta-analysis, Barbara Chmielewska and colleagues1 note significant increases in maternal death and stillbirths during the COVID-19 pandemic. They link these outcomes to reduced access to maternal health services, stating that in low-income and middle-income countries (LMICs), remote antenatal care appointments are less feasible because of technological shortcomings in these countries. Full-Text PDF Open AccessEffects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysisGlobal maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression. Some outcomes show considerable disparity between high-resource and low-resource settings. There is an urgent need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises. Full-Text PDF Open Access