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      Stillbirths in Germany: On the rise, but no additional increases during the first COVID‐19 lockdown

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          Abstract

          Objective

          To examine possible changes in the rate of stillbirths in Germany during the first COVID‐19 lockdown.

          Methods

          Population‐level data of live births and stillbirths occurring between January 1995 and July 2020 were used and negative binomial regression was applied to estimate the rate of stillbirths in this period. The actual rate was compared to the expected figure for 2020.

          Results

          A steady increase in stillbirths was detected in Germany since 2013. The stillbirth rate for January to July 2020 (4.148) was slightly lower than that of the same period in 2019 (4.242). Furthermore, all monthly rates of stillbirths during the first half of 2020 lie inside the 95% prediction interval of expected stillbirth rates for this period.

          Conclusion

          A growing body of studies on the indirect effect of the COVID‐19 pandemic on stillbirths shows mixed and context‐dependent evidence. In contrast to other European countries, stillbirth rates have been on the rise in Germany in the last decade. However, stillbirth rates during the first half of 2020 were not higher than expected. The results suggest that stillbirth rates have not changed during the first‐wave COVID‐19 lockdown in this high‐income setting. However, further studies on the causes of the increasing trend in stillbirths in Germany are needed.

          Synopsis

          The rate of stillbirths has been increasing in Germany over the last decade but was not higher than expected during the first wave of COVID‐19.

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          Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis

          Barbara Chmielewska, Imogen Barratt, Rosemary Townsend … (2021)
          Background The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has been undertaken. We aimed to assess the collective evidence on the effects on maternal, fetal, and neonatal outcomes of the pandemic. Methods We did a systematic review and meta-analysis of studies on the effects of the pandemic on maternal, fetal, and neonatal outcomes. We searched MEDLINE and Embase in accordance with PRISMA guidelines, from Jan 1, 2020, to Jan 8, 2021, for case-control studies, cohort studies, and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications, and intrapartum and neonatal outcomes before and during the pandemic. We also planned to record any additional maternal and offspring outcomes identified. Studies of solely SARS-CoV-2-infected pregnant individuals, as well as case reports, studies without comparison groups, narrative or systematic literature reviews, preprints, and studies reporting on overlapping populations were excluded. Quantitative meta-analysis was done for an outcome when more than one study presented relevant data. Random-effects estimate of the pooled odds ratio (OR) of each outcome were generated with use of the Mantel-Haenszel method. This review was registered with PROSPERO (CRD42020211753). Findings The search identified 3592 citations, of which 40 studies were included. We identified significant increases in stillbirth (pooled OR 1·28 [95% CI 1·07–1·54]; I 2=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 [1·22–1·53; I 2=0%, two studies [both from low-income and middle-income countries], 1 237 018 and 2 224 859 pregnancies) during versus before the pandemic. Preterm births before 37 weeks' gestation were not significantly changed overall (0·94 [0·87–1·02]; I 2=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 [0·84–0·99]; I 2=63%; 12 studies, 159 987 and 635 118 pregnancies), where spontaneous preterm birth was also decreased (0·81 [0·67–0·97]; two studies, 4204 and 6818 pregnancies). Mean Edinburgh Postnatal Depression Scale scores were higher, indicating poorer mental health, during versus before the pandemic (pooled mean difference 0·42 [95% CI 0·02–0·81; three studies, 2330 and 6517 pregnancies). Surgically managed ectopic pregnancies were increased during the pandemic (OR 5·81 [2·16–15·6]; I 2=26%; three studies, 37 and 272 pregnancies). No overall significant effects were identified for other outcomes included in the quantitative analysis: maternal gestational diabetes; hypertensive disorders of pregnancy; preterm birth before 34 weeks', 32 weeks', or 28 weeks' gestation; iatrogenic preterm birth; labour induction; modes of delivery (spontaneous vaginal delivery, caesarean section, or instrumental delivery); post-partum haemorrhage; neonatal death; low birthweight (<2500 g); neonatal intensive care unit admission; or Apgar score less than 7 at 5 min. Interpretation Global 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. Funding None.
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            National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis

            Hannah Blencowe, Simon Cousens, Fiorella Bianchi Jassir … (2016)
            Previous estimates have highlighted a large global burden of stillbirths, with an absence of reliable data from regions where most stillbirths occur. The Every Newborn Action Plan (ENAP) targets national stillbirth rates (SBRs) of 12 or fewer stillbirths per 1000 births by 2030. We estimate SBRs and numbers for 195 countries, including trends from 2000 to 2015.
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              Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study

              Ashish KC, Rejina Gurung, Mary V. Kinney … (2020)
              Summary Background The COVID-19 pandemic response is affecting maternal and neonatal health services all over the world. We aimed to assess the number of institutional births, their outcomes (institutional stillbirth and neonatal mortality rate), and quality of intrapartum care before and during the national COVID-19 lockdown in Nepal. Methods In this prospective observational study, we collected participant-level data for pregnant women enrolled in the SUSTAIN and REFINE studies between Jan 1 and May 30, 2020, from nine hospitals in Nepal. This period included 12·5 weeks before the national lockdown and 9·5 weeks during the lockdown. Women were eligible for inclusion if they had a gestational age of 22 weeks or more, a fetal heart sound at time of admission, and consented to inclusion. Women who had multiple births and their babies were excluded. We collected information on demographic and obstetric characteristics via extraction from case notes and health worker performance via direct observation by independent clinical researchers. We used regression analyses to assess changes in the number of institutional births, quality of care, and mortality before lockdown versus during lockdown. Findings Of 22 907 eligible women, 21 763 women were enrolled and 20 354 gave birth, and health worker performance was recorded for 10 543 births. From the beginning to the end of the study period, the mean weekly number of births decreased from 1261·1 births (SE 66·1) before lockdown to 651·4 births (49·9) during lockdown—a reduction of 52·4%. 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). In terms of quality of care, intrapartum fetal heart rate monitoring decreased by 13·4% (−15·4 to −11·3; p<0·0001), and breastfeeding within 1 h of birth decreased by 3·5% (−4·6 to −2·6; p=0·0032). The immediate newborn care practice of placing the baby skin-to-skin with their mother increased by 13·2% (12·1 to 14·5; p<0·0001), and health workers' hand hygiene practices during childbirth increased by 12·9% (11·8 to 13·9) during lockdown (p<0·0001). Interpretation Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. Funding Grand Challenges Canada.
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                Author and article information

                Contributors
                Maxi S. Kniffka:
                ORCID: https://orcid.org/0000-0001-6603-2724
                kniffka@demogr.mpg.de
                Journal
                Journal ID (nlm-ta): Int J Gynaecol Obstet
                Journal ID (iso-abbrev): Int J Gynaecol Obstet
                Journal ID (doi): 10.1002/(ISSN)1879-3479
                Journal ID (publisher-id): IJGO
                Title: International Journal of Gynaecology and Obstetrics
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Print): 0020-7292
                ISSN (Electronic): 1879-3479
                Publication date (Electronic): 07 August 2021
                Publication date (Print): December 2021
                Publication date PMC-release: 07 August 2021
                Volume: 155
                Issue: 3 ( doiID: 10.1002/ijgo.v155.3 )
                Pages: 483-489
                Affiliations
                [ 1 ] Laboratory of Fertility and Well‐Being Max Planck Institute for Demographic Research Rostock Germany
                [ 2 ] Department of Sociology and Demography University of Rostock Rostock Germany
                [ 3 ] Department of Sociology and Demography Chair of Demography University of Rostock Rostock Germany
                [ 4 ] Laboratory of Statistical Demography Max Planck Institute for Demographic Research Rostock Germany
                [ 5 ] Laboratory of Population Health Max Planck Institute for Demographic Research Rostock Germany
                Author notes
                [*] [* ] Correspondence

                Maxi S. Kniffka, Max Planck Institute for Demographic Research, Konrad‐Zuse‐Straße 1, 18057 Rostock, Germany; Department of Sociology and Demography, Chair of Demography, University of Rostock, Ulmenstraße 69, 18057 Rostock, Germany.

                Email: kniffka@ 123456demogr.mpg.de

                Author information
                https://orcid.org/0000-0001-6603-2724
                https://orcid.org/0000-0002-9744-5393
                https://orcid.org/0000-0003-2131-6269
                https://orcid.org/0000-0001-8252-7903
                Article
                Publisher ID: IJGO13832
                DOI: 10.1002/ijgo.13832
                PMC ID: 9087793
                PubMed ID: 34287881
                SO-VID: 7b34a02d-2ae5-4cbb-a72a-f263025952f9
                Copyright © © 2021 International Federation of Gynecology and Obstetrics
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 11 July 2021
                Date accepted : 19 July 2021
                Page count
                Figures: 1, Tables: 1, Pages: 7, Words: 5169
                Categories
                Subject: Clinical Article
                Subject: Clinical Articles
                Subject: Obstetrics
                Custom metadata
                source-schema-version-number 2.0
                cover-date December 2021
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.1.5 mode:remove_FC converted:10.05.2022

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: covid‐19,fetal death,germany,lockdown,stillbirth
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: covid‐19, fetal death, germany, lockdown, stillbirth

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