Health care in pregnancy during the COVID-19 pandemic and pregnancy outcomes in six low- and-middle-income countries: Evidence from a prospective, observational registry of the Global Network for Women’s and Children’s Health

Objective: To assess, on a population basis, the medical care for pregnant women in specific geographic regions of six countries before and during the first year of the coronavirus disease 2019 (COVID-19) pandemic in relationship to pregnancy outcomes. Design: Prospective, population-based study. Setting: Communities in Kenya, Zambia, the Democratic Republic of the Congo, Pakistan, India and Guatemala. Population: Pregnant women enrolled in the Global Network for Women’s and Children’s Health’s Maternal and Newborn Health Registry. Methods: Pregnancy/delivery care services and pregnancy outcomes in the pre-COVID-19 time-period (March 2019–February 2020) were compared with the COVID-19 time-period (March 2020–February 2021). Main outcome measures: Stillbirth, neonatal mortality, preterm birth, low birthweight and maternal mortality. Results: Across all sites, a small but statistically significant increase in home births occurred between the pre-COVID-19 and COVID-19 periods (18.9% versus 20.3%, adjusted relative risk [aRR] 1.12, 95% CI 1.05–1.19). A small but significant decrease in the mean number of antenatal care visits (from 4.1 to 4.0, p = <0.0001) was seen during the COVID-19 period. Of outcomes evaluated, overall, a small but significant decrease in low-birthweight infants in the COVID-19 period occurred (15.7% versus 14.6%, aRR 0.94, 95% CI 0.89–0.99), but we did not observe any significant differences in other outcomes. There was no change observed in maternal mortality or antenatal haemorrhage overall or at any of the sites. Conclusions: Small but significant increases in home births and decreases in the antenatal care services were observed during the initial COVID-19 period; however, there was not an increase in the stillbirth, neonatal mortality, maternal mortality, low birthweight, or preterm birth rates during the COVID-19 period compared with the previous year. Further research should help to elucidate the relationship between access to and use of pregnancy-related medical services and birth outcomes over an extended period. The Eunice Kennedy Shriver Global Network for Women's and Children Health's (Global Network) Maternal and Newborn Health Registry (MNHR) is a prospective, population‐based observational study that was initiated in 2009. 22 , 23 All pregnant women in defined geographic communities that include approximately 300–500 births annually, are identified and enrolled. For this study, we analysed population‐based data from the eight to ten communities at the sites in western Kenya, Zambia (Kafue and Chongwe), the Democratic Republic of the Congo (North and South Ubangi Provinces), Pakistan (Thatta in Sindh Provence), India (Belagavi and Nagpur) and Guatemala (Chimaltenango). Registry administrators, trained study healthcare staff, identified pregnant women in their respective communities and following consent, enrolled them in the MNHR. 22 , 23 Once a pregnant woman was identified, the registry administrators obtained basic health information at enrolment, and recorded the date of last menstrual period or early ultrasound report to assess gestational age and other basic demographic information. A follow‐up visit was carried out following delivery to collect information on pregnancy outcomes as well as the health care received during delivery. The maternal and newborn health statuses were collected at 42 days post‐delivery. The study outcomes were based on medical record reviews and birth attendant and family interviews. Birthweights for babies born in facilities were available from the birth certificates or hospital records and for home deliveries, babies were weighed within 48 hours of birth by the registry administrators using standardised study scales. During the onset of the COVID‐19 pandemic, some of the participating sites went through lockdown periods, when the field activities were either partially or fully halted. However, the registry administrators continued to collect information on pregnancy and neonatal outcomes either through telephone contacts or by making home visits. Stillbirths were defined as fetuses born at 20 weeks of gestation or more with no signs of life including movement, cry or respirations. Neonatal deaths were defined as the death of any live‐born infant, regardless of gestational age or birthweight, who died before 28 days of life. Maternal mortality was defined as death of the mother at any time in the pregnancy and up to 42 days postpartum. The outcome of miscarriages and medical terminations of pregnancy included any pregnancy registered in the MNHR that ended before 20 weeks of gestation. Although we attempted to capture every pregnancy ending at 20 weeks or more, some pregnancies, especially those with an early termination or miscarriage, may not be captured in the MNHR. Also, especially in Pakistan and Guatemala, the babies delivered at home may not have been weighed because of the absence of personal contact because of the COVID‐19 pandemic. However, most of the other data were collected by telephone in those sites. The analysis population included women screened for the MNHR who were eligible, consented and delivered at 20 weeks of gestation between March 2019 and February 2021. The pre‐COVID‐19 period was defined as extending from March 2019 through February 2020 and the COVID‐19 period from March 2020 through February 2021, based on the World Health Organization's declaration of a global pandemic. 24 We compared the pregnancy and delivery care practices of women in the pre‐COVID‐19 time‐period and during the COVID‐19 time‐period. For analyses, we combined data from the Democratic Republic of the Congo, Zambian and Kenyan sites as the African sites, and Belagavi and Nagpur, India, as the Indian sites. Pakistan and Guatemala were considered separately. The percentage of women with four or more antenatal care (ANC) visits as well as the mean number of ANC visits in women at each site, the percentage of deliveries by a physician and the percentage of women delivering at home were analysed by site and year overall and for each of the two time‐periods. Maternal mortality ratios, the rates of stillbirths, neonatal deaths until 28 days, early neonatal deaths before 7 days, perinatal mortality defined as stillbirths plus early neonatal mortality, low birthweight (<2500 g) and preterm birth (<37 weeks of gestation at delivery) were compared by site and overall, for both time‐periods. The rates of stillbirth and perinatal mortality are reported per 1000 live births and stillbirths, whereas neonatal mortality was calculated per 1000 live births. For display purposes, the absolute changes in healthcare measures were calculated as the values during COVID‐19 minus the pre‐pandemic values. Finally, we calculated the relative risks (RR) and corresponding 95% CI from Poisson models for categorical variables and normal distribution model for continuous ANC visits with generalised estimating equations to account for the correlation of outcomes within community, accounting for site and the interaction of pre‐COVID‐19 or during COVID‐19 and site. We ran the same models adjusting for the potential confounders, maternal age, education and parity. All statistical analyses were conducted in SAS v. 9.4 (SAS Institute, Cary, NC, USA). This study was reviewed and approved by the ethics committees of participating research sites (INCAP, Guatemala; University of Zambia, Zambia; Moi University, Kenya; Aga Khan University, Pakistan; Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo), KLE University's Jawaharlal Nehru Medical College, Belagavi, India; Lata Medical Research Foundation, Nagpur, India), the institutional review boards at each US partner university and the data coordinating centre (RTI International). All women provided informed consent for participation in the study, including data collection and the follow‐up visits.