Anyway the Robot must have had pretty easy lines to learn as usually all he repetitively said was “Danger Will Robinson” or “warning warning.” I am beginning to know how he must have felt as I have been repetitively warning now for a few months that the current Pandemic will inevitably cause an increase in stillbirths. I take no pleasure at all in saying there is more and more evidence emerging to support my view.
Last week the Scots , who seem to be able to report population based perinatal outcomes faster than anyone else in the world, reported a concerning spike in stillbirth rates in the last quarter.
To add to this yesterday a research letter titled Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic was published in JAMA. This was reporting a pre v during pandemic study in St George’s University Hospital, London . They compared pregnancy outcomes from 1681 births occurring at the hospital between October 1, 2019, to January 31, 2020 (preceding the first reported UK cases of COVID-19), with 1718 births from February 1, 2020, to June 14, 2020. Outcomes included stillbirth, preterm birth, cesarean delivery, and neonatal unit admission.Interestingly they did not find an increase in preterm birth, cesarean or neonatal admission between the two time frames. They did report fewer women with hypertension in the pandemic group (3.7% vs 5.7%; P = .005) but, of concern, here are their stillbirth findings:
The incidence of stillbirth was significantly higher during the pandemic period (n = 16 [9.31 per 1000 births]; none associated with COVID-19) than during the prepandemic period (n = 4 [2.38 per 1000 births]) (difference, 6.93 per 1000 births [95% CI, 1.83-12.0]; P = .01) and the incidence of stillbirth was significantly higher when late terminations for fetal abnormality were excluded during the pandemic period (6.98 per 1000 births vs 1.19 in the prepandemic period; difference, 5.79 [95% CI, 1.54-10.1]; P = .01).
During the pandemic period, 19 patients with COVID-19 were hospitalized in the study site maternity department. None of the pregnant women who experienced stillbirth had symptoms suggestive of COVID-19, nor did the postmortem or placental examinations suggest SARS-CoV-2 infection.
The authors suggest some plausible sounding reasons for the increase in numbers of stillbirths:
1. A direct consequence of SARS-CoV-2 infection.
2. indirect effects such as reluctance to attend hospital when needed (eg, with reduced fetal movements), fear of contracting infection, or not wanting to add to the National Health Service burden.
3. Changes in obstetric services secondary to staff shortages or reduced antenatal visits, ultrasound scans, and/or screening.
Number 1 seems pretty unlikely especially as none of the mothers had any symptoms. Of course asymptomatic cases of COVID-19 are pretty common but I wouldn’t think it likely that a woman with mild enough symptoms to evade detection would suffer a stillbirth caused by this infection, especially if there was no sign of the infection at autopsy.
Number 2 is certainly possible but I am always pretty concerned when mothers are bashed in this way. While it is certainly common to hear the lament “ if only she had presented to care sooner” I would also suggest that it takes two to tango, meaning that in this context the care provider may also have been reluctant to ask her to attend hospital in an attempt to ‘protect’ her, and they could have been equally, if not more, concerned about not wanting to add to the NHS burden!
Which brings me to number 3, changes in obstetric services. These have occurred , not only in this hospital but, across the globe. The fact that the authors of this letter also point to fewer women being reported with hypertension isn’t at all likely to mean that there were actually fewer women, just that fewer women with hypertension were detected. Good antenatal care targets detection and management of many pregnancy problems and the fact that this really common problem was missed is an important indicator that maternity services are not as good as they should be. Further if this kind of problem is being missed then other problems that also increase risk of stillbirth are likely to be missed too.
As the Australian college of midwives recent report indicates women are not impressed with changes in maternity care in Australia and are saying things like : I am concerned non-evidence based knee jerk reactions are becoming policy. I wouldn’t think Australian women are unique in the world in this regard.
So what can be done? We need to abandon the changes to obstetric services that were made in haste and are obviously causing harm and return to thorough evidence based maternity care as quickly as possible. We need to rethink what is actually needed to protect woman from COVID-19 and that this is probably NOT telehealth, and full PPE. We need to understand that if we don’t know that a woman is developing hypertension during pregnancy that that most certainly puts her and her baby in harms way FAR more than the possible threat of harm to her and her baby from COVID-19. So those who have made these initial practice changes in haste need to be equally hastily and have a rethink. There are things like single patient use sphygmomanometers and midwives providing antenatal care in the woman’s own home that are far better safer choices!!
Hopefully someone other than Will Robinson is listening to these concerns and will act before many more babies die!