\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{``Impact of covid 19 pandemic on maternofetal outcome in pregnant women
with severe anemia:a retrospective case control study''}



\author[1]{Meenakshi Singh}%
\author[1]{Manju Puri}%
\author[1]{VIDHI CHAUDHARY}%
\author[1]{TRIVENI GS}%
\author[1]{AISHWARYA KAPUR}%
\author[1]{GUNJAN gunjan}%
\author[1]{MANISHA PATEL}%
\author[1]{VINITA KUMARI}%
\affil[1]{Lady Hardinge Medical College}%


\vspace{-1em}



  
  \date{May 07, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objective: To study the impact of COVID 19 pandemic on the prevalence,
clinical profile, and pregnancy outcomes of women with severe anaemia.
Design: Retrospective Case Control study Setting: Department of
Obstertrics ,Tertiary care hospital of Delhi Population:Antenatal women
\textgreater{}26 weeks and Hemoglobin\textless{}7 gm\% Methods: After
satisfying inclusion and exclusion criteria, cases were taken for a
duration of six months during COVID pandemic, covid cases and controls
from period six months post covid. Main outcome measures: Prevalence of
anemia, Anemia indices and maternofetal outcome. Results: Total 4031
women delivered in study period compared to 6659 in control period.
74.7\% and 51.6\% were anaemic in study and control groups respectively
(p \textless{} 0.001). Mean hemoglobin level was significantly lower in
cases compared to the controls. Microcytic hypochromic anemia was most
common morphological type of anemia in both groups. Serum ferritin,
serum iron, serum B12 and folic acid levels among cases were
significantly (p\textless{}0.05) lower as compared to controls. Odds of
foetal growth restriction was 48\% higher among cases as compared to
controls. The odds ratio of new-born complications such as low birth
weight 2.49 (95\%CI: 1.04-5.91) and need for nursery or NICU admission
4.84 (95\%CI: 0.48-48.24) was higher in cases as compared to controls.
Low birth rate was higher in cases and was found to be statistically
significant. Conclusion: India needs to focus on minimizing the indirect
effects of the pandemic on the maternal and perinatal outcomes. Funding:
none%
\end{abstract}%



\sloppy


\textbf{TITLE: ``Impact of covid 19 pandemic on maternofetal outcome in
pregnant women with severe anemia:a retrospective case control study''}

\textbf{Authors:}

Primary Author

1.Dr Meenakshi Singh

Professor

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:drmeenakshisingh99@gmail.com

Co authors

2.Dr Manju Puri

Director Professor

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id :drmanjupuri@gmail.com

3.Dr Vidhi Choudhary

Professor

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:drvidh@gmail.com

4.Dr Aishwarya Kapur

Assistant Professor

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:aish9kapur@gmail.com

5.Dr Triveni GS

Assistant Professor

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:drtriveni.gs@gmail.com

6.Dr Gunjan

Post Graduate Resident

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:drgunjan3010@gmail.com

7.Dr Manisha Patel

Post Graduate Resident

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:drsinghmanisha1992@gmail.com

8.Dr Vinita

Post Graduate Resident

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:vinita2k14@gmail.com

\textbf{CORRESPONDING AUTHOR}

Dr Meenakshi Singh

Designation:Professor

Department of Obstetrics and Gynaecology

Lady Harding Medical College

New Delhi 110011

Email id:drmeenakshisingh99@gmail.com

Address:Flat no 8667,C8,Vasantkunj,New delhi,110070

Contact no.:9560511155

\textbf{Running title: Covid impact on maternofetal outcome in severe
anemia in pregnancy}

\textbf{ABSTRACT}

\textbf{Objective:} To study the impact of COVID 19 pandemic on the
prevalence, clinical profile, and pregnancy outcomes of women with
severe anaemia.

\textbf{Design:} Retrospective Case Control study

\textbf{Setting:} Department of Obstertrics ,Tertiary care hospital of
Delhi

\textbf{Population:} Antenatal women \textgreater{}26 weeks and
Hemoglobin\textless{}7 gm\%

\textbf{Methods:} After satisfying inclusion and exclusion criteria,
cases were taken for a duration of six months during COVID pandemic,
covid cases and controls from period six months post covid.

\textbf{Main outcome measures} : Prevalence of anemia, Anemia indices
and maternofetal outcome.

\textbf{Results} : Total 4031 women delivered in study period compared
to 6659 in control period. 74.7\% and 51.6\% were anaemic in study and
control groups respectively (p \textless{} 0.001). Mean hemoglobin level
was significantly lower in cases compared to the controls. Microcytic
hypochromic anemia was most common morphological type of anemia in both
groups. Serum ferritin, serum iron, serum B12 and folic acid levels
among cases were significantly (p\textless{}0.05) lower as compared to
controls. Odds of foetal growth restriction was 48\% higher among cases
as compared to controls. The odds ratio of new-born complications such
as low birth weight 2.49 (95\%CI: 1.04-5.91) and need for nursery or
NICU admission 4.84 (95\%CI: 0.48-48.24) was higher in cases as compared
to controls. Low birth rate was higher in cases and was found to be
statistically significant.

\textbf{Conclusion} : India needs to focus on minimizing the indirect
effects of the pandemic on the maternal and perinatal outcomes.

\textbf{Funding} : none

\textbf{BACKGROUND}

Anemia is a major public health problem in developing countries. It is
the most common nutritional disease in pregnancy with significant
adverse impact on maternal and perinatal morbidity and mortality. In
2019, the global prevalence of anemia in pregnant woman was estimated to
be 36.5\% (1). As per recent NFHS 5 report the prevalence of anaemia in
pregnant women in India is 45.7\% and 54.3\% in urban and rural areas
respectively(2) The important causes of anemia in developing countries
include poor nutrition, inadequate iron in diet, poor absorption of iron
due to hookworm infestation, diarrhea,, suboptimal screening and
treatment and too early, too soon and too many child births. Routine
antenatal and postnatal iron supplementation free of cost is an
important Government initiative to reduce anemia in pregnancy. Despite
this, anemia remains unabated due to poor compliance to iron
supplementation by beneficiaries and lack of commitment among the health
care providers to screen and treat pregnant women for anemia. Covid 19
pandemic further disrupted the antenatal care services due to lockdowns
and related travel restrictions, loss of jobs and related financial
constraints and reluctance of pregnant women to visit health facilities
for the fear of contracting infection (3). The lower socioeconomic
strata were the worst affected. As with previous epidemics there was a
sudden increase in demand and redirection of the workforce towards the
management of COVID pandemic and resultant reduction in provision of
routine health services.(4) Although COVID-19 disease itself did not
directly increase the maternal mortality but resulted in unsupervised
pregnancies adversely affecting maternal health. (5, 6)

This study was initiated to study the impact of COVID 19 pandemic on the
prevalence, clinical profile and pregnancy outcomes of women with severe
anaemia

\textbf{MATERIALS and METHODS}

This record based retrospective comparative observational study was
conducted in the department of Obstetrics and Gynaecology at LHMC and
SSK Hospital, Delhi for a duration of six months from July 2020 to
December 2020 during COVID pandemic (study group) and a six month Pre
COVID period from July 2019 to December 2019 (control group). The study
included all antenatal women admitted at a gestational age
\textgreater{}26 weeks (third trimester) with severe anaemia that is
haemoglobin level of \textless{}7 gm\% for delivery as per ICMR
classification for grading of anemia in pregnancy. The case records of
patients having severe anaemia due to acute blood loss like antepartum
haemorrhage were not included in the study.

After obtaining ethical clearance from institutional ethics committee
eligible subjects were identified from birth entry register and case
records were retrieved. A proforma was used to record the relevant
demographic details including maternal age, registration status of
pregnancy, parity, gestational age in weeks at admission,
inter-conception period, gestational age in weeks at delivery, presence
of factors contributing to anaemia (such as intolerance to iron,
non-availability and lack of antenatal care) ; clinical complaints at
admission (exercise intolerance, easy fatiguability, breathlessness
etc); clinical data on management (such as injectable iron, Vit B12,
blood transfusion); complications (like abruption, postpartum
haemorrhage, ICU admission, need of intubation , maternal death, foetal
growth restriction); mode of delivery (vaginal delivery, LSCS);
laboratory investigations (hemoglobin level, peripheral smear, serum
ferritin, serum B12 and folic acid levels and foetal outcome (
gestational age, live or still birth, birth weight, APGAR score and need
of nursery/NICU admission).

\textbf{Statistical analysis:} The data collected during the study was
entered in Microsoft Excel spreadsheet. The statistical analysis was
performed using the Statistical Package for the Social Sciences for
Windows version 18 (SPSS Inc., Chicago, IL, USA). Descriptive statistics
were expressed as mean \selectlanguage{ngerman}± standard deviation for continuous variables and
frequencies or percentages for categorical variables. Normality of the
data distribution were assessed with the Kolmogorov-Smirnov test.
Depending upon normality of data, appropriate tests were used.
Chi-square test and students t-test were applied to see the difference
between study and control groups for baseline clinical and laboratory
characteristics and outcomes. Univariate logistic regression models were
used to assess the association between year and maternal/perinatal
outcomes. Odds ratios and 95\% confidence intervals were presented. A
p value of less than 0.05 was considered statistically significant.

\textbf{RESULTS}

In the present study, 4031 women delivered in study period compared to
6659 in control period. Of these (3010/4031) 74.7\% and (3446/6659)
51.6\% were anaemic in study and control groups respectively. (p
\textless{} .001). The overall prevalence of severe anemia was (51/4031)
1.27 \% and (77/6659) 1.16\% respectively amongst all deliveries in the
study and control groups respectively \textbf{(p value =0.616).} (Table
1).

In the present study a total of 51 case records from study group and 77
case records from control group were analysed. Table no 2 shows the
comparison between the epidemiological details including mean age of the
pregnant women, their antenatal registration status, inter-conception
period, mean gestational age at delivery and antenatal prophylactic iron
supplementation.

Table no 3 describes the clinical presentation at the time of admission
in the study and control groups. Majority of women were asymptomatic in
both the groups at the time of admission. Of the symptomatic women
breathlessness was the commonest symptom in both the groups. There was
no difference in the clinical presentation in both the groups.

All patients received blood transfusion in both the groups in view of
severe anemia whereas 5.9\% and 2.6\% in study and control groups
received platelet transfusion. Parenteral iron was administered to 9.8\%
patients in study group compared to none in control group whereas
parenteral Vit B12 was given to 19.6\% and 26.8\% patients in the study
and control groups respectively.

The vaginal delivery rates were higher among control group (83.1\%) as
compared to study group (76.5\%) however the difference was
statistically not significant.

Mean hemoglobin level was significantly lower in study group than the
control group. Microcytic hypochromic anemia was the most common
morphological type of anemia in both study and control groups. Serum
ferritin, serum iron, serum B12 and folic acid levels among study group
were significantly (p\textless{}0.05) lower as compared to control group
.

The odds ratio of maternal death in study group was 6.46 (95\%CI:
0.70-59.63) as compared to control group. The odds ratio of maternal
complications was such as abruption 2.34 (95\%CI: 0.37-14.54),
postpartum haemorrhage 2.65 (95\% CI: 0.99-7.04) and ICU admission 3.29
(95\% CI: 0.78-13.80) in study group compared to control group but the
difference was statistically not significant as the confidence intervals
were very wide. Odds of foetal growth restriction was 48\% higher among
study group as compared to control group (Table 4).

The odds ratio of neonatal deaths in study group was 4.84 (95\%CI:
0.48-48.24) compared to control group. The odds ratio of new-born
complications such as low birth weight 2.49 (95\%CI: 1.04-5.91) and need
for nursery or NICU admission 4.84 (95\%CI: 0.48-48.24) was higher in
study group as compared to control group. Low birth rate was higher in
study group and was found to be statistically significant. Odds of still
birth was 5\% higher in study group as compared to control group (Table
6).

\textbf{DISCUSSION}

\textbf{Main findings}

Anemia is the second most common cause of maternal death in India and
contributes to about 80\% of the maternal deaths in Southeast Asia.
(7,8,9) Anemia is also an established risk factor for intrauterine
growth restriction, leading to perinatal and neonatal mortality and
morbidity. Anaemia during pregnancy increase the risk of hemorrhage,
labor complications and puerperal sepsis to the mother. The gestational
complications, maternal mortality, low birth weight and, adverse birth
outcome is among the major adverse impacts of anaemia in pregnancy in
most developing countries, particularly in south-east Asia. (10,11)

Though COVID-19 has not affected maternal and fetal outcomes directly,
the present study highlights the indirect effects of COVID-19 on
pregnancy outcomes. Overall prevalence of anemia as well as severe
anemia was more in study group that is during the pandemic compared to
control group in the pre pandemic period. Two-third of pregnant women
with severe anemia (60.8\%) did not have any contact with health care
provider as they were asymptomatic and due to pandemic related factors
like lack of transport, finances, or fear of contagion from health care
centres. The reduced number of antenatal visits and increased
unregistered pregnancies contributed to an increase in pregnancy
complications and related morbidity and mortality. In the study by Davis
et al (12), it was found that women preferred home deliveries instead of
institutional deliveries in the fear of contagion from delivery
institutes. It is possible that the number of cases of severe anaemia
during pandemic in the study group are not reflective of the actual
numbers. The inter-conception period \textless{}2 years was
significantly higher in study group compared to control group. This
difference is likely due to an increase in sexual exposure consequent to
couples staying home due to lock down coupled with inaccessibility to
family planning services both with respect to contraception and safe
abortion services. In present study 47.1\% of women in study group did
not receive routine iron and folic acid supplementation during
pregnancy, with resultant anemia and related complications. A decreased
mean hemoglobin level was observed in study group as compared to control
group. Similar observation has been reported in other Indian studies.
(13, 14)

In a study by Justman et al., the rate of caesarean deliveries,
including emergency cesarean deliveries, was similar between the two
periods: 22.1\% (164/742) in control group vs. 24.1\% (147/610) during
the pandemic group (15). However, contrast to this the caesarean section
rates were higher in study group (23.5\%) compared to control group
(16.9\%) but the difference was statistically not significant. The
factors contributing to an increased caesarean section rate in study
group might be due to the difficulty in close fetal monitoring in PPE
and unexpected delays in decision delivery interval due to COVID
protocols .

More patients in study group required ICU admission due to an increase
in complications like abruption and postpartum haemorrhage. An increase
in the maternal mortality rate was also observed. In the present study,
the odds ratio of maternal deaths among study group was higher as
compared to control group OR 6.46 (95\% CI 0.70-59.63). Similar findings
have been reported in the studies by Kumari et al., (1·54 95\% CI:
0·56--4·25) and Lumbreras-Marquez et al., (1·36 95\% CI: 1·22--1·53)
(16,17). In present study the odds ratio for preterm birth before 37
weeks' gestation was 1.22 times (95\% CI: 0.59-2.51) in study group as
compared to control group. Similar findings were observed in the studies
by Khalil et al., Main et al., McDonnell et al., and Sun et al, where
odds ratio for pandemic group was higher than control group such as 1·11
(95\% CI: 0·85--1·44), 1·01 (95\% CI: 0·99--1·03), 1·18 (95\% CI:
0·91--1·54), 1·03 (95\% CI: 0·30--3·51) respectively (18,19,20,21)

In present study, odds of still birth was 5\% higher among pandemic as
compared to control group which was similar to pattern found in study by
Kumar et al., (1·26, 955 CI: 1·00--1·58) but opposed to the study by
Caniglia et al., where odds of stillbirth were higher in control groups
as compared to pandemic group (0·96, 95\% CI: 0·73--1·26) {[}22,23{]}.
In the study by KC et al., the institutional stillbirth rate increased
from 14 per 1000 total births before lockdown to 21 per 1000 total
births during lockdown (p=0·0002), and institutional neonatal mortality
increased from 13 per 1000 livebirths to 40 per 1000 livebirths
(p=0·0022) {[}24).

Only 2 out of 55 women among cases were COVID-19 positive and none of
them required intensive care and had live births implying that COVID-19
infection itself did not contribute substantially to an increase in
maternal or fetal morbidity or mortality in the study population.

\textbf{Strengths and limitations}

The present study was carried out in a government setup of a developing
country reflecting the true face of disrupted antenatal care during the
covid pandemic.Despite the set up catering free of cost services to the
pregnant woman ,the pandemic hindered adequate service provision.

Few limitations of the study include that it is a single-center study at
a tertiary hospital so the results cannot be generalized. Second, the
analysis includes only those women who were admitted to the facility,
while pregnant women with anaemia attending outpatient department were
not included. Lastly, as it is a retrospective, observational study with
a small sample size it does not take in to account other independent
factors affecting delay in patient seeking antenatal care and
influencing maternofetal outcomes. Large multicentric studies and
worldwide surveys are needed to identify and guide management of
antenatal women during pandemics to optimize outcomes .

\textbf{Interpretation}

As in other pandemics, the healthcare system faced a great challenge
during the COVID- 19 pandemic, showing its indirect effects on the
vulnerable antenatal group and an increase in pregnancy-related
complications.

\textbf{CONCLUSIONS}

The indirect effects of COVID-19 on maternal and perinatal outcomes were
observed. Although it is likely that other factors might have been at
play,the lower mean Hb levels,lower iron reserves and B12 levels,
increased caesarean section rate, increased perinatal mortality rate,
increased number of stillbirths together with the increased likelihood
of abruption point towards disruptions in the provision of antepartum
care and compromised quality of intrapartum care. As India continues to
implement public health measures to curb the spread of COVID-19, there
is need to reduce the indirect effects of the pandemic on the maternal
and perinatal outcomes. The country is presently battling the third wave
of the COVID-19 pandemic, therefore these results may be useful for
local, provincial, and national program planning.

\textbf{Disclosure of interests:~} none

\textbf{Contribution to authorship} :

Author's contribution: MS contributed in planning, carrying out,
analysing, and writing up of the work, MP contributed in the conception
and final proof check of the manuscript ,VC ,AK,TG,G,MP and VK
contributed in data collection and analysis.

\textbf{Details of ethics approval:} Ethical approval taken by
Institutional Ethics Committee of Lady Harding Medical College,New Delhi
.

\textbf{Funding} : none

\textbf{REFERENCES}

1.MOHFW. India fact sheet. Available at:
http://rchiips.org/nfhs/NFHS-5\_FCTS/FactSheet \_TG.pdf. Accessed on 26
January 2022.

2.World Health Organization. Health Topic. Anemia. Geneva: World Health
Organization; 2021. Available from:
https://www.who.int/health-topics/anaemia\#tab=tab\_1. Accessed 26
January, 2022.

3. . World Health Organization. Coronavirus disease 2019 (COVID-19)
Situation Report - 44. Gevena: WHO; 2020. Available from:
https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200304-sitrep44-COVID-
19.pdf. Accessed on 30th Jan 2022

4. Wilhelm JA, Helleringer S. Utilization of non-Ebola health care
services during Ebola outbreaks: a systematic review and meta-analysis.
J Glob Health 2019;9(1):010406.

5.Burki T. The indirect impact of COVID-19 on women.Lancet Infect Dis
2020; 20: 904--05. World Health Organization. Managing epidemics: key
facts about major deadly diseases. Geneva: WHO; 2018. Available
from:https://www.who.int/emergencies/diseases/managing-epidemics/interactive.pdf.
Accessed on 30\textsuperscript{th} Jan 2022.

6. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et
al. Early estimates of the indirect effects of the COVID-19 pandemic on
maternal and childrtality in low-income and middle-income countries: a
modelling study. Lancet Glob Health 2020;8(7):e 901- 8

7. Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca
F, et al. Global, regional, and national trends in haemoglobin
concentration and prevalence of total and severe anaemia in children and
pregnant and non-pregnant women for 1995-2011: a systematic analysis of
population-representative data. Lancet Glob Health 2013;1(1):e16-25.

8. Rukuni R, Knight M, Murphy MF, Roberts D, Stanworth SJ. Screening for
iron deficiency and iron deficiency anaemia in pregnancy: a structured
review and gap analysis against UK national screening criteria. BMC
Pregnancy Childbirth 2015;15:269.

9. WHO. Global Health Observatory Data Repository: World Health
Statistics. Geneva: World Health Organization; 2016

10. Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan
D, et al. Global, regional, and national estimates of levels of preterm
birth in 2014: a systematic review and modelling analysis. Lancet Glob
Health 2019;7(1):e37-46.

11. Figueiredo ACMG, Gomes-Filho IS, Silva RB, Pereira PPS, Mata FAFD,
Lyrio AO, et al. Maternal anemia and low birth weight: a systematic
review and meta-analysis. Nutrients 2018;10(5):601

12. Davis-Floyd R, Gutschow K, Schwartz DA. Pregnancy, Birth and the
COVID-19 pandemic in the United States. Med Anthropol 2020;39(5):413-27.

13.Sharma JB. Nutritional anemia during pregnancy in nonindustrialized
countries. In: Studd J (ed.).Progress inObstetrics and Gynaecology.
Edinburgh: Churchill Livingstone,2003;15: 103--122.

14. Patra S, Pasrija S, Trivedi SS, Puri M. Maternal and
perinataloutcome in patients with severe anemia in pregnancy.Int
JGynaecol Obstet2005;91: 164--165.

15. Justman N, Shahak G, Gutzeit O, Ben Zvi D, Ginsberg Y, Solt I, et
al. Lockdown with a price: the impact of the COVID-19 pandemic on
prenatal care and perinatal outcomes in a tertiary care center. Isr Med
Assoc J 2020;22(9):533-7.

16. Kumari V, Mehta K, Choudhary R. COVID-19 outbreak and decreased
hospitalisation of pregnant women in labour. Lancet Glob Health
2020;8:e1116--17.

17. Lumbreras-Marquez MI, Campos-Zamora M, Seifert SM, Kim J,
Lumbreras-Marquez J, Vazquez-Alaniz F, et al. Excess maternal deaths
associated with Coronavirus Disease 2019 (COVID-19) in Mexico. Obstet
Gynecol 2020;136(6):1114-6.

18. Khalil A, von Dadelszen P, Draycott T, Ugwumadu A, O'Brien P, Magee
L. Change in the incidence of stillbirth and preterm delivery during the
COVID-19 pandemic. JAMA 2020;324:705.

19. Main EK, Chang SC, Carpenter AM, Wise PH, Stevenson DK, Shaw GM, et
al. Singleton preterm birth rates for racial and ethnic groups during
the coronavirus disease 2019 pandemic in California. Am J Obstet Gynecol
2021;224(2):239-41.

20. McDonnell S, McNamee E, Lindow SW, O'Connell MP. The impact of the
COVID-19 pandemic on maternity services: a review of maternal and
neonatal outcomes before, during and after the pandemic. Eur J Obstet
Gynecol Reprod Biol 2020;255:172--6.

21. Sun SY, Guazzelli CAF, de Morais LR, Dittmer FP, Augusto MN, Soares
AC, et al. Effect of delayed obstetric labor care during the COVID-19
pandemic on perinatal outcomes. Int J Gynaecol Obstet 2020;151(2):287-9.

22. Kumar M, Puri M, Yadav R, Biswas R, Singh M, Chaudhary V, et al.
Stillbirths and the COVID-19 pandemic: looking beyond SARS-CoV-2
infection. Int J Gynaecol Obstet 2021;153(1):76-82.

23. Caniglia EC, Magosi LE, Zash R, Diseko M, Mayondi G, Mabuta J, et
al. Modest reduction in adverse birth outcomes following the COVID-19
lockdown. Am J Obstet Gynecol 2021;224(6):615.e1-2.

24. KC A, Gurung R, Kinney MV, Sunny AK, Moinuddin M, Basnet O, et al.
Effect of the COVID-19 pandemic response on intrapartum care,
stillbirth, and neonatal mortality outcomes in Nepal: a prospective
observational study. Lancet Glob Health 2020;8(10):e1273-81.

TABLES

\textbf{Table 1. Grading of severity of anemia in women admitted in
pandemic and control group}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Grading of severity of anemia of delivered women}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Study group} \textbf{(n=4031)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Control group (n=6659)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{P value}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
No anemia (Hb\textgreater{}=11g\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1021 (25.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3223 (48.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Anaemia\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3010 (74.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3436 (51.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Mild anemia (Hb 10-10.9 g\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1750 (43.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1820 (27.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}0.00001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Moderate anemia (Hb 7 -9.9g\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1207 (29.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1539 (23.1\%\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}0.0.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Severe anemia (Hb \textless{}7 g\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
51 (1.27\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
77 (1.16\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.616\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}



\textbf{Table 2. Comparison of the epidemiological characteristics of
pregnant women with severe anaemia in pregnancy}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Variable} & \textbf{Study group (n=51)} & \textbf{Control group
(n=77)} & \textbf{P value}\tabularnewline
\midrule
\endhead
\textbf{Age (in years)} & 27.9\selectlanguage{ngerman}±3.1 & 24.8\selectlanguage{ngerman}±4.0 & P=0.000\tabularnewline
\textbf{Parity} & & &\tabularnewline
\textbf{Primigravida} & 36(70.6\%) & 50(64.9\%) & P=0.504\tabularnewline
\textbf{Multigravida} & 15(29.4\%) & 27(35.1\%) &\tabularnewline
\textbf{Antenatal registration} & \textbf{Antenatal registration} &
\textbf{Antenatal registration} & \textbf{Antenatal
registration}\tabularnewline
Yes & 20 (39.2\%) & 43 (55.8\%) & P=0.065\tabularnewline
No & 31 (60.8\%) & 34 (44.2\%) &\tabularnewline
\textbf{Inter-conception period\textsuperscript{\#}} & (N=15/51) &
(N=27/77) & P=0.0001\tabularnewline
\textless{} 2 years & 13(86.6\%) & 7(25.9\%) &\tabularnewline
\textgreater{}2 years & 2 (13.3\%) & 20 (74.1\%) &\tabularnewline
\textbf{Gestational age (in weeks) at delivery} & 36.9\selectlanguage{ngerman}±1.6 & 37.0\selectlanguage{ngerman}±2.1 &
P=0.903\tabularnewline
\textbf{Preterm birth (\textless{} 37 weeks of gestation)} & &
&\tabularnewline
Yes & 31 (61.8\%) & 43 (55.8\%) & 0.579\tabularnewline
No & 20 (38.2\%) & 34 (44.2\%) &\tabularnewline
\textbf{Antenatal iron supplementation} & \textbf{Antenatal iron
supplementation} & \textbf{Antenatal iron supplementation} &
\textbf{Antenatal iron supplementation}\tabularnewline
Yes & 27 (52.9\%) & 65 (84.4\%) & P=0.0001\tabularnewline
No & 24 (47.1\%) & 12 (15.6\%) &\tabularnewline
\bottomrule
\end{longtable}

\textbf{\#Multigravida (n=42)}

\textbf{Table 3. Comparison of clinical characteristics of severely
anaemic pregnant women in the two groups}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Variable} & \textbf{Study group (n=51)} & \textbf{Control group
(n=77)} & \textbf{P value}\tabularnewline
\midrule
\endhead
\textbf{Clinical complaints and presentation at time of admission*} &
\textbf{Clinical complaints and presentation at time of admission*} &
\textbf{Clinical complaints and presentation at time of admission*} &
\textbf{Clinical complaints and presentation at time of
admission*}\tabularnewline
Breathlessness (n=27) & 11 (21.6\%) & 16 (20.8\%) &
P=0.099\tabularnewline
Pedal oedema & 0 (0.0\%) & 5 (6.5\%) &\tabularnewline
Dizziness & 0 (0.0\%) & 2 (2.6\%) &\tabularnewline
Anasarca & 2 (3.9\%) & 0 (0.0\%) &\tabularnewline
Asymptomatic & 41 (80.4\%) & 57 (74.0\%) &\tabularnewline
\bottomrule
\end{longtable}

\textbf{*Multiple responses}

\textbf{Table 4: Laboratory parameters related to Anemia}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Variable} & \textbf{Study group N=51} & \textbf{Control group
N=77} & \textbf{P value}\tabularnewline
\midrule
\endhead
Mean Hb (g/dl) & 5.4\selectlanguage{ngerman}±0.8 & 6.1\selectlanguage{ngerman}±1.2 & P=0.0004\tabularnewline
\textbf{Peripheral smear (Morphological type of anaemia)} &
\textbf{Peripheral smear (Morphological type of anaemia)} &
\textbf{Peripheral smear (Morphological type of anaemia)} &
\textbf{Peripheral smear (Morphological type of anaemia)}\tabularnewline
Microcytic hypochromic & 27 (52.9) & 39 (50.6) & P=0.359\tabularnewline
Dimorphic anaemia & 9 (17.6) & 8 (10.4) &\tabularnewline
Macrocytic & 15 (29.4) & 30(39.0) &\tabularnewline
\textbf{Serum ferritin and iron levels in microcytic +dimorphic anaemia}
& \textbf{Serum ferritin and iron levels in microcytic +dimorphic
anaemia} & \textbf{Serum ferritin and iron levels in microcytic
+dimorphic anaemia} & \textbf{Serum ferritin and iron levels in
microcytic +dimorphic anaemia}\tabularnewline
Serum ferritin (ng/ml) & 5.6\selectlanguage{ngerman}±5.2 & 8.6\selectlanguage{ngerman}±4.1 & P=0.0004\tabularnewline
Serum iron (\selectlanguage{greek}µ\selectlanguage{english}g/dl) & 25.3\selectlanguage{ngerman}±6.5 & 36.2\selectlanguage{ngerman}±5.8 &
P\textless{}0.001\tabularnewline
\textbf{Serum B12 and folate levels in macrocytic and dimorphic anaemia}
& \textbf{Serum B12 and folate levels in macrocytic and dimorphic
anaemia} & \textbf{Serum B12 and folate levels in macrocytic and
dimorphic anaemia} & \textbf{Serum B12 and folate levels in macrocytic
and dimorphic anaemia}\tabularnewline
Serum B12 (pg/ml) & 110.4\selectlanguage{ngerman}±34.5 & 140.7\selectlanguage{ngerman}±42.1 &
P\textless{}0.001\tabularnewline
Serum Folic acid (ng/l) & 4.1\selectlanguage{ngerman}±1.7 & 4.8\selectlanguage{ngerman}±2.3 & P=0.018\tabularnewline
\bottomrule
\end{longtable}

\textbf{*Multiple responses}

\textbf{Table 5. Comparison of pregnancy outcome in study and control
groups}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Pregnancy outcomes} & \textbf{Study group (n=51)} &
\textbf{Control group (n=77)} & \textbf{OR, 95\% CI, P
value}\tabularnewline
\midrule
\endhead
\textbf{Abruption} & \textbf{Abruption} & \textbf{Abruption} &
\textbf{Abruption}\tabularnewline
Yes & 3 (5.9\%) & 2 (2.6\%) & 2.34, 0.37-14.54, 0.914\tabularnewline
No & 48 (94.1\%) & 75 (97.4\%) &\tabularnewline
\textbf{Postpartum haemorrhage} & \textbf{Postpartum haemorrhage} &
\textbf{Postpartum haemorrhage} & \textbf{Postpartum
haemorrhage}\tabularnewline
Yes & 12 (23.5\%) & 8 (10.4\%) & 2.65, 0.99-7.04, 0.050\tabularnewline
No & 39 (76.5\%) & 69 (89.6\%) &\tabularnewline
\textbf{ICU admission} & \textbf{ICU admission} & \textbf{ICU admission}
& \textbf{ICU admission}\tabularnewline
Yes & 6 (11.8\%) & 3 (3.9\%) & 3.29, 0.78-13.80, 0.103\tabularnewline
No & 45 (88.2\%) & 74 (96.1\%) &\tabularnewline
\textbf{Need of intubation} & \textbf{Need of intubation} & \textbf{Need
of intubation} & \textbf{Need of intubation}\tabularnewline
Yes & 6 (11.8\%) & 3 (3.9\%) & 3.29, 0.78-13.80, 0.103\tabularnewline
No & 45 (88.2\%) & 74 (96.1\%) &\tabularnewline
\textbf{Maternal death} & \textbf{Maternal death} & \textbf{Maternal
death} & \textbf{Maternal death}\tabularnewline
Yes & 4 (7.8\%) & 1 (1.3\%) & 6.46, 0.70-59.63, 0.099\tabularnewline
No & 47 (92.2\%) & 76 (98.7\%) &\tabularnewline
\textbf{Foetal growth restriction} & \textbf{Foetal growth restriction}
& \textbf{Foetal growth restriction} & \textbf{Foetal growth
restriction}\tabularnewline
Yes & 22 (43.1\%) & 26 (33.8\%) & 1.48, 0.71-3.08, 0.284\tabularnewline
No & 29 (56.9\%) & 51 (66.2\%) &\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 6. Perinatal outcome in Pregnant women with severe anemia}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Outcome} & \textbf{Study group (n=51)} & \textbf{Control group
(n=77)} & \textbf{OR, 95\% CI, P value}\tabularnewline
\midrule
\endhead
\textbf{Birth} & \textbf{Birth} & \textbf{Birth} &
\textbf{Birth}\tabularnewline
Still birth & 9 (17.6\%) & 13 (16.9\%) & 1.05, 0.41-2.68,
0.910\tabularnewline
Live birth & 42 (82.4\%) & 64 (83.1\%) &\tabularnewline
\textbf{Neonatal death*} & N=42/51 & N=64/77 &\tabularnewline
Yes & 3 (7.1\%) & 1 (1.6\%) & 4.84, 0.48-48.24, 0.178\tabularnewline
No & 39 (92.9\%) & 63 (98.4\%) &\tabularnewline
\textbf{Baby birth weight\textless{} 2500 grams*} & N=42/51 & N=64/77
&\tabularnewline
Yes & 32 (76.2\%) & 36 (56.3\%) & 2.49, 1.04-5.91, 0.038\tabularnewline
No & 10 (23.8\%) & 28 (43.8\%) &\tabularnewline
\textbf{5 min APGAR score \textless{} 7 *} & N=42/51 & N=64/51
&\tabularnewline
Yes & 3 (7.1\%) & 1 (1.6\%) & 4.84, 0.48-48.24, 0.178\tabularnewline
No & 39 (92.9\%) & 63 (98.4\%) &\tabularnewline
\textbf{Need of nursery/ NICU admission*} & N=42 & N=64 &\tabularnewline
Yes & 3 (7.1\%) & 1 (1.6\%) & 4.84, 0.48-48.24, 0.178\tabularnewline
No & 39 (92.9\%) & 63 (98.4\%) &\tabularnewline
\bottomrule
\end{longtable}

* Percentages are calculated out of live borns in each group

\selectlanguage{english}
\FloatBarrier
\end{document}

