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 <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.