Indirect impact of SARS-CoV-2 pandemic on pregnancy and childbirth outcomes: A nine-month long experience from a university center in Lombardy

Midwives' stress and burnout during the Omicron wave in Italy: An observational survey

AIM

To evaluate midwives' level of stress and burnout during the COVID-19 Omicron phase in Italy. Secondary aims were to explore the impact of the pandemic on midwives' personal dimensions and professional activities and potential supporting strategies.

DESIGN

A mixed-methods study was undertaken from July to December 2022.

METHODS

Data were collected using a national online observational survey. Descriptive and inferential analyses were performed to evaluate stress, burnout and the impact of the pandemic on personal and professional dimensions. A deductive qualitative approach was used to analyse open-ended responses, that were merged with quantitative data following a convergent mixed-methods approach.

RESULTS

A total of 1944 midwives participated in the survey. The stress summary score mean was 10.34, and 562 midwives (28.91%) experienced burnout. The intention to reduce working hours was reported by 202 midwives (10.39%), with 60.40% (n = 122) of them experiencing burnout. The intention to leave clinical practice within the following 2 years was reported by 239 (12.29%), with 68.20% (n = 163) of them experiencing burnout. All the personal dimensions and professional activities considered were defined by more than half of midwives as being impacted 'Moderately' or 'To a great extent' by pandemic. Stress and burnout frequencies increased when the midwives' perception of the pandemic effects was higher. Potential supporting strategies described by midwives as the most important in increasing their ability to cope with the pandemic were 'Women's awareness of the midwives' role' (n = 1072; 55.14%) and 'Family and friends' emotional support' (n = 746; 38.38%).

CONCLUSION

Our findings suggested strategies to support a positive and safe working environment for midwives during a pandemic emergency, with potential transferability to similar contexts when human resources are lacking. It is recommended that maternity services provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout.

IMPACT

Studies conducted during the first COVID-19 pandemic wave showed an increased level of stress, anxiety, burnout, post-traumatic stress disorder and depression experienced by healthcare professionals; moreover, midwives experienced drastic changes in care pathways and policies with struggles identified when providing high-quality woman-centred care following pandemic restrictions. Although it is recommended, there is lack of knowledge about long-term psychological effects of COVID-19 for midwives. Our study highlights that during the Omicron wave midwives experienced a high level of stress and burnout with an impact on individual dimensions and professional activities. Their stress and burnout were influenced by several factors, including restrictions in place, lack of organizational acknowledgement, work overload and need for extra childcare cover. Maternity services should provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout. Recommendations on how to facilitate this are suggested.

REPORTING METHOD

During the writing process, we referred to 'The Strengthening the Reporting of Observational Studies Epidemiology Statement', the guidelines for reporting observational studies from the Equator network.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Work overload conditions negatively impacted on the quality of maternity services. Improving organizational aspects, reducing working hours, promoting family and friends' emotional support and improving women's awareness of midwife's role were the main strategies reported by midwives. These suggestions for ensuring a positive and safe working environment for midwives during a pandemic emergency could potentially be applied to similar situations where human resources are lacking.

Indirect impact of SARS-CoV-2 pandemic on incidence of maternal primary cytomegalovirus and Toxoplasma gondii infection in pregnancy

OBJECTIVE

Public health interventions promoted during the SARS-CoV-2 pandemic to control viral spread have impacted the occurrence of other communicable disease. Yet no studies have focused on perinatal infections with the potential for neonatal sequelae, including cytomegalovirus (CMV) and Toxoplasma gondii (TG). Here we investigate whether incidence rates of maternal primary CMV and TG infection in pregnancy were affected by the implementation of pandemic-related public health measures.

METHODS

A retrospective study including all pregnant women with confirmed primary CMV or TG infection in pregnancy, managed between 2018 and 2021 at two university centers. The incidence rate was calculated as the number of CMV and TG infections per 100 consultations with a 95% confidence interval (CI). Data were compared between pre-pandemic (2018-2019) and pandemic (2020 and 2021) years. The Newcombe Wilson with Continuity Correction method was employed to compare incidence rates.

RESULTS

The study population included 215 maternal primary CMV and 192 TG infections. Rate of maternal primary CMV infection decreased in 2021 compared with 2018-2019 (4.49% vs 6.40%, attributable risk [AR] 1.92, P = 0.019). By contrast, the rate of TG infection substantially increased in 2020 (6.95% vs 4.61%, AR 2.34, P = 0.006). Close contact with cats was more common among patients with TG infection in 2020 and 2021 than among pre-pandemic TG-infected women (26.3% and 24.4% vs 13.3%, P = 0.013).

CONCLUSION

Pandemic-related public health interventions and associated behavioral and lifestyle changes exerted a divergent effect on the incidence of primary CMV and TG infection in pregnancy, likely due to modulation of exposure to risk factors for these infections.

Intrapartum Quality of Care among Healthy Women: A Population-Based Cohort Study in an Italian Region

Although the quality of care during childbirth is a maternity service's goal, less is known about the impact of the birth setting dimension on provision of care, defined as evidence-based intrapartum midwifery practices. This study's aim was to investigate the impact of hospital birth volume (≥1000 vs. <1000 births/year) on intrapartum midwifery care and perinatal outcomes. We conducted a population-based cohort study on healthy pregnant women who gave birth between 2018 and 2022 in Lombardy, Italy. A total of 145,224 (41.14%) women were selected from nationally linked databases. To achieve the primary aim, log-binomial regression models were constructed. More than 70% of healthy pregnant women gave birth in hospitals (≥1000 births/year) where there was lower use of nonpharmacological coping strategies, higher likelihood of epidural analgesia, episiotomy, birth companion's presence at birth, skin-to-skin contact, and first breastfeeding within 1 h (p-value < 0.001). Midwives attended almost all the births regardless of birth volume (98.80%), while gynecologists and pediatricians were more frequently present in smaller hospitals. There were no significant differences in perinatal outcomes. Our findings highlighted the impact of the birth setting dimension on the provision of care to healthy pregnant women.

The impact of gestational weeks of Coronavirus disease 2019 (COVID-19) infection on perinatal outcomes

BACKGROUND

To evaluate the relationship between coronavirus disease 2019 (COVID-19) infection at different time points during pregnancy and perinatal outcomes.

METHODS

This retrospective study included 611 women who hospitalized for delivery between December 7 and April 30, 2023. Based on the different pregnancy weeks infected with COVID-19, the participants were divided into four groups: Group 1 (14-27+6 weeks gestation), Group 2 (28-36+6 weeks gestation), Group 3 (37-39+6 weeks gestation), and Group 4 (≥ 40 weeks gestation). Data including maternal demographic characteristics, clinical profiles, and perinatal outcomes were analyzed.

RESULTS

There were no significant differences in maternal demographic characteristics among the four groups (P > 0.05). Compared to Groups 3 and 4, a higher rate of fever was noted in Groups 1 and 2 (P < 0.05). The frequency of preeclampsia and gestational diabetes mellitus showed a decreasing trend as pregnancy progressing (P < 0.05). Preterm delivery and neonatal intensive care unit admission were more frequently observed in Groups 1 and 2 than in Groups 3 and 4 (P < 0.05). Multivariate logistic regression analysis demonstrated that the timing of gestation in which COVID-19 was infected was not associated with preterm delivery and neonatal intensive care unit admission (P > 0.05), whereas gestational age at COVID-19 infection was negatively associated with the occurrence of preeclampsia and gestational diabetes mellitus (P < 0.05).

CONCLUSIONS

Gestational age at COVID-19 infection is a simple parameter that predicts adverse perinatal outcomes to aid clinicians in determining to provide early enhanced prenatal care and increased monitoring to reduce maternal complications.

Higher NICU admissions in infants born at ≥35 weeks gestational age during the COVID-19 pandemic

Background

Increasing evidence has shown that the COVID-19 pandemic has had a profound negative impact on vulnerable populations and a significant effect on maternal and neonatal health. We observed an increase in the percentage of infants admitted to NICU from 8% to 10% in the first year of the pandemic. This study aimed to compare the delivery room outcomes, NICU admissions and interventions, and neonatal outcomes two years before and during the pandemic.

Methods

This was a retrospective study in a public hospital between pre-COVID-19 (April 2018-December 2019) and COVID-19 (April 2020-December 2021). Data were obtained from all live births at ≥35 weeks gestation (GA). Maternal and neonatal demographics, delivery room (DR), and NICU neonatal outcomes were compared between the study periods using simple bivariable generalized estimating equations (GEE) regression. Multivariable GEE logistic regression analysis was performed to adjust for the effects of baseline differences in demographics on the outcomes.

Results

A total of 9,632 infants were born ≥35 weeks gestation during the study period (pre-COVID-19 n = 4,967, COVID-19 n = 4,665). During the COVID-19 period, there was a small but significant decrease in birth weight (33 g); increases in maternal diabetes (3.3%), hypertension (4.1%), and Hispanic ethnicity (4.7%). There was a decrease in infants who received three minutes (78.1% vs. 70.3%, p < 0.001) of delayed cord clamping and increases in the exclusive breastfeeding rate (65.9% vs. 70.1%, p < 0.001), metabolic acidosis (0.7% vs. 1.2%, p = 0.02), NICU admission (5.1% vs. 6.4%, p = 0.009), antibiotic (0.7% vs. 1.7%, p < 0.001), and nasal CPAP (1.2% vs. 1.8%, p = 0.02) use. NICU admissions and nasal CPAP were not significantly increased after adjusting for GA, maternal diabetes, and hypertension; however, other differences remained significant. Maternal hypertension was an independent risk factor for all these outcomes.

Conclusion

During the COVID-19 pandemic period, we observed a significant increase in maternal morbidities, exclusive breastfeeding, and NICU admissions in infants born at ≥35 weeks gestation. The increase in NICU admission during the COVID-19 pandemic was explained by maternal hypertension, but other adverse neonatal outcomes were only partly explained by maternal hypertension. Socio-economic factors and other social determinants of health need to be further explored to understand the full impact on neonatal outcomes.

Increased newborn NICU admission for evaluation of hypoxic-ischemic encephalopathy during COVID-19 pandemic in a public hospital

Background

Prenatal and perinatal care of pregnant mothers has been adversely affected during the COVID-19 pandemic. Hypoxic-ischemic encephalopathy (HIE) is a leading cause of neonatal death and long-term neurological disabilities. Therapeutic hypothermia is effective for neonatal HIE. This study evaluated the effect of the pandemic on neonatal HIE.

Methods

This retrospective single-center study compared neonatal HIE evaluation and hypothermia treatment between pre-COVID-19 pandemic (1 January 2018-31 December 2019) and COVID-19 pandemic (1 January 2020-31 December 2021) periods. Infants with abnormal neurological examination and or significant metabolic acidosis were admitted to NICU for evaluation of HIE and therapeutic hypothermia. Demographics, NICU admission and interventions, and neonatal outcomes were compared between infants born during the two periods using χ², t-test, and Wilcoxon rank-sum test as appropriate. Statistical Process Control charts show the yearly proportion of infants evaluated for HIE and those treated with therapeutic hypothermia.

Results

From the pre-pandemic to the pandemic period, the proportion of infants that met HIE screening criteria increased from 13% to 16% (p < 0.0001), the proportion of infants admitted to NICU for HIE evaluation increased from 1% to 1.4% (p = 0.02), and the maternal hypertension rates of the admitted infants increased from 30% to 55% (p = 0.006). There was no difference in the proportions of the infants diagnosed with HIE (0.7% vs. 0.9%, p = 0.3) or treated with therapeutic hypothermia (0.2% vs. 0.3%, p = 0.3) between the two periods. There were no differences in the HIE severity and outcomes of the infants treated with therapeutic hypothermia between the two periods.

Conclusion

During the COVID-19 pandemic, we observed a significant increase in NICU admission for HIE evaluation. While we did not find significant increases in neonatal HIE and the need for therapeutic hypothermia, larger studies are needed for a comprehensive assessment of the impact of the COVID-19 pandemic on neonatal HIE.

Indirect effects of the COVID-19 pandemic on risk of gestational diabetes and factors contributing to increased risk in a multiethnic population: a retrospective cohort study

BACKGROUND

The COVID-19 pandemic has had indirect effects on pregnancy outcomes. There is limited data on the impact on gestational diabetes (GDM) in diverse populations and the possible underlying mediators. This study aimed to assess the risk of GDM pre-COVID-19 and in two distinct pandemic exposure periods, and to determine the potential factors contributing to increased risk in a multiethnic population.

METHODS

A multicentre, retrospective cohort study was performed of women with singleton pregnancy receiving antenatal care at three hospitals two years pre-COVID-19 (January 2018 - January 2020), first year of COVID-19 with limited pandemic-mitigating restrictions (February 2020 - January 2021) and second year of COVID-19 with stringent restrictions (February 2021 - January 2022). Baseline maternal characteristics and gestational weight gain (GWG) were compared between cohorts. The primary outcome was GDM, assessed using univariate and multivariate generalised estimating equations models.

RESULTS

28,207 pregnancies met the inclusion criteria, 14,663 pregnancies two years pre-COVID-19, 6,890 in COVID-19 Year 1 and 6,654 in COVID-19 Year 2. Maternal age increased across exposure periods (30.7 ± 5.0 years pre-COVID-19 vs 31.0 ± 5.0 years COVID-19 Year 1 vs 31.3 ± 5 years COVID-19 Year 2; p < 0.001). There were increases in pre-pregnancy body mass index (BMI) (25.5 ± 5.7 kg/m² vs 25.7 ± 5.6 kg/m² vs 26.1 ± 5.7 kg/m²; p < 0.001), proportion who were obese (17.5% vs 18.1% vs 20.7%; p < 0.001) and proportion with other traditional risk factors for GDM including South Asian ethnicity and prior history of GDM. Rate of GWG and proportion exceeding recommended GWG increased with pandemic exposure (64.3% vs 66.0% vs 66.6%; p = 0.009). GDM diagnosis increased across exposure periods (21.2% vs 22.9% vs 24.8%; p < 0.001). Both pandemic exposure periods were associated with increased risk of GDM on univariate analysis, only COVID-19 Year 2 remaining significantly associated after adjusting for maternal baseline characteristics and GWG (OR 1.17 [1.06, 1.28], p = 0.01).

CONCLUSIONS

Diagnosis of GDM increased with pandemic exposure. Progressive sociodemographic changes and greater GWG may have contributed to increased risk. However, exposure to the second year of COVID-19 remained independently associated with GDM after adjusting for shifts in maternal characteristics and GWG.

COVID-19 pandemic and neonatal birth weight: a systematic review and meta-analysis

OBJECTIVES

Lockdown was implemented in many countries during the pandemic, which led to myriad changes in pregnant women's lives. However, the potential impacts of the COVID-19 pandemic on neonatal outcomes remain unclear. We aimed to evaluate the association between the pandemic and neonatal birth weight.

STUDY DESIGN

This was a systematic review and meta-analysis of the previous literature.

METHODS

We searched the MEDLINE and Embase databases up to May 2022 and extracted 36 eligible studies that compared neonatal birth weight between the pandemic and the prepandemic period. The following outcomes were included: mean birth weight, low birth weight (LBW), very low birth weight (VLBW), macrosomia, small for gestational age (SGA), very small for gestational age (VSGA), and large for gestational age (LGA). Statistical heterogeneity among studies was assessed to determine whether a random effects model or fixed effects model was conducted.

RESULTS

Of the 4514 studies identified, 36 articles were eligible for inclusion. A total of 1,883,936 neonates during the pandemic and 4,667,133 neonates during the prepandemic were reported. We identified a significant increase in mean birth weight (pooled mean difference [95% confidence interval (CI)] = 15.06 [10.36, 19.76], I² = 0.0%, 12 studies) and a reduction in VLBW (pooled OR [95% CI] = 0.86 [0.77, 0.97], I² = 55.4%, 12 studies). No overall effect was identified for other outcomes: LBW, macrosomia, SGA, VSGA, and LGA. There was publication bias for mean birth weight with a borderline significance (Egger's P = 0.050).

CONCLUSION

Pooled results showed the pandemic was significantly associated with an increase in mean birth weight and a reduction in VLBW, but not for other outcomes. This review provided clues about the indirect effects of the pandemic on neonatal birth weight and more healthcare measures needed to improve neonatal long-term health.

Impacts of COVID-19 pandemic on preterm birth: a systematic review and meta-analysis

OBJECTIVES

The COVID-19 pandemic has significantly affected healthcare systems and daily well-being. However, the reports of the indirect impacts of the pandemic on preterm birth remain conflicting. We performed a meta-analysis to examine whether the pandemic altered the risk of preterm birth.

STUDY DESIGN

This was a systematic review and meta-analysis of the previous literature.

METHODS

We searched MEDLINE and Embase databases until March 2022 using appropriate keywords and extracted 63 eligible studies that compared preterm between the COVID-19 pandemic period and the prepandemic period. A random effects model was used to obtain the pooled odds of each outcome. The study protocol was registered with PROSPERO (No. CRD42022326717).

RESULTS

The search identified 3827 studies, of which 63 reports were included. A total of 3,220,370 pregnancies during the COVID-19 pandemic period and 6,122,615 pregnancies during the prepandemic period were studied. Compared with the prepandemic period, we identified a significant decreased odds of preterm birth (PTB; <37 weeks' gestation; pooled odds ratio [OR; 95% confidence interval (CI)] = 0.96 [0.94, 0.98]; I2 = 78.7%; 62 studies) and extremely PTB (<28 weeks' gestation; pooled OR [95% CI] = 0.92 [0.87, 0.97]; I2 = 26.4%; 25 studies) during the pandemic, whereas there was only a borderline significant reduction in the odds of very PTB (<32 weeks' gestation; pooled OR [95% CI] = 0.93 [0.86, 1.01]; I2 = 90.1%; 33 studies) between the two periods. There was significant publication bias for PTB.

CONCLUSION

Pooled results suggested the COVID-19 pandemic was associated with preterm birth, although there was only a borderline significant reduction for very PTB during the pandemic compared with the prepandemic period. Large studies showed conflicting results, and further research on whether the change is related to pandemic mitigation measures was warranted.

COVID-19 and Gestational Diabetes: The Role of Nutrition and Pharmacological Intervention in Preventing Adverse Outcomes

Pregnant women with GDM affected by COVID-19 seem to be at higher risk of adverse maternal and neonatal outcomes, especially those with overweight or obesity. Good glycemic control seems to be the most effective measure in reducing the risk of GDM and severe COVID-19. For such purposes, the Mediterranean diet, micronutrient supplementation, and physical activity are considered the first line of treatment. Failure to achieve glycemic control leads to the use of insulin, and this clinical scenario has been shown to be associated with an increased risk of adverse maternal and neonatal outcomes. In this review, we explore the current evidence pertaining to the pathogenesis of SARS-CoV-2 leading to the main complications caused by COVID-19 in patients with GDM. We also discuss the incidence of complications caused by COVID-19 in pregnant women with GDM according to their treatment.