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Iranifard E, Yas A, Mansouri Ghezelhesari E, Taghipour A, Mahmoudinia M, Latifnejad Roudsari R. Treatment suspension due to the coronavirus pandemic and mental health of infertile patients: a systematic review and meta-analysis of observational studies. BMC Public Health 2024; 24:174. [PMID: 38218778 PMCID: PMC10787415 DOI: 10.1186/s12889-023-17628-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/31/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Access to fertility treatments is considered a reproductive right, but because of the quarantine due to the coronavirus pandemic most infertility treatments were suspended, which might affect the psychological and emotional health of infertile patients. Therefore, this study was conducted to review the mental health of infertile patients facing treatment suspension due to the coronavirus pandemic. METHODS This study was conducted based on the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guideline. The Web of Science, PubMed, Embase, Scopus, and Cochrane library databases were searched by two independent researchers, without time limitation until 31 December 2022. All observational studies regarding the mental health of infertile patients facing treatment suspension including anxiety, depression, and stress were included in the study. Qualitative studies, editorials, brief communications, commentaries, conference papers, guidelines, and studies with no full text were excluded. Quality assessment was carried out using Newcastle-Ottawa Scale by two researchers, independently. The random effects model was used to estimate the pooled prevalence of mental health problems. Meta-regression and subgroup analysis were used to confirm the sources of heterogeneity. RESULTS Out of 681 studies, 21 studies with 5901 infertile patients were systematically reviewed, from which 16 studies were included in the meta-analysis. The results of all pooled studies showed that the prevalence of anxiety, depression, and stress in female patients was 48.4% (95% CI 34.8-62.3), 42% (95% CI 26.7-59.4), and 55% (95% CI 45.4-65), respectively. Additionally, 64.4% (95% CI 50.7-76.1) of patients wished to resume their treatments despite the coronavirus pandemic. CONCLUSION Treatment suspension due to the coronavirus pandemic negatively affected the mental health of infertile patients. It is important to maintain the continuity of fertility care, with special attention paid to mental health of infertile patients, through all the possible measures even during a public health crisis.
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Affiliation(s)
- Elnaz Iranifard
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atefeh Yas
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Ali Taghipour
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Epidemiology, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Malihe Mahmoudinia
- Maternal and Neonatal Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Obstetrics and Gynecology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Robab Latifnejad Roudsari
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
- Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.
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Li X, Yao X, Bai L, Lu R, Geng S, Ling X, Wen J, Hu L. Impacts of the COVID-19 pandemic on early pregnancy outcomes among women undergoing frozen-thawed embryo transfer: a retrospective cohort study. HUM FERTIL 2023; 26:1477-1484. [PMID: 37668066 DOI: 10.1080/14647273.2023.2251680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 06/27/2023] [Indexed: 09/06/2023]
Abstract
The effect of COVID-19 pandemic on early pregnancy outcomes among women undergoing frozen-thawed embryo transfer (FET) remains unclear. We aimed to evaluate whether early pregnancy outcomes were altered in patients undergoing FET during the pandemic. In this retrospective cohort study, women conceived through FET in 2016-2021 from two hospitals in China were included. The early pregnancy outcomes were compared using Logistic regression model, including biochemical pregnancy rate (BPR), clinical pregnancy rate (CPR), and early pregnancy loss rate (EPLR). A total of 16,669 (67.2%) and 6,113 (26.8%) FET cycles enrolled before and during the pandemic, respectively. Univariate analyses showed that women undergoing FET during the pandemic had significantly increased BPR (72.9% vs. 69.7%) and CPR (59.5% vs. 55.0%), and significantly decreased EPLR (13.7% vs. 16.7%) compared to pre-pandemic (all P < 0.001). Moreover, after adjustment, the results were in accordance with univariate analysis for CPR [adjusted OR (95%CI) = 1.08 (1.01-1.14)] and EPLR [adjusted OR (95%CI) = 0.82 (0.73-0.91)], while the statistical significance between BPR and the pandemic disappeared. In summary, women conceived by FET did not have a reduced possibility of clinical pregnancy and a higher risk of early pregnancy loss during the pandemic compared with the pre-pandemic.
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Affiliation(s)
- Xin Li
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Xiaodie Yao
- Nanjing Maternity and Child Health Care Institute, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Lijing Bai
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, China
| | - Renjie Lu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, China
- School of Health Management, Southern Medical University, Guangzhou, Guangdong, China
| | - Shijie Geng
- Nanjing Maternity and Child Health Care Institute, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Xiufeng Ling
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Juan Wen
- Nanjing Maternity and Child Health Care Institute, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Lingmin Hu
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, China
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Correa Rancel M, Sosa Comino E, Leon-Larios F, Suárez Hernández Y, Carballo Lorenzo J, Gomez-Baya D, Baez Quintana D. Emotional Distress Caused by the Measures Taken in Assisted Reproductive Treatments during the COVID-19 Confinement in Spain. J Clin Med 2023; 12:7069. [PMID: 38002682 PMCID: PMC10672169 DOI: 10.3390/jcm12227069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/10/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
During the pandemic, assisted reproductive treatments suffered from major disruptions in their terms due to the restrictions imposed. The objective of this study is to evaluate the level of anxiety of women whose treatments were either suspended or delayed. METHODS Descriptive cross-sectional study conducted between April and May 2020. The State-Trait Anxiety Inventory was applied by telephone in a Spanish adapted version. The research also included social, personal, and work aspects which may be involved in the challenging situation. RESULTS A total of 115 patients participated in the study (73.7%). Women showed a mean in trait anxiety of 17.79 (SD = 8.80) and a mean in state anxiety of 19.95 (SD = 9.08). Neither the type of treatment nor the time of infertility were predictors of trait anxiety or state anxiety. Greater age pressure and more worry were associated to greater trait and state anxiety (p < 0.001). The most common emotional reactions to discontinuation of fertility treatments were sadness and anxiety. CONCLUSIONS Discontinuation of fertility treatments due to confinement restrictions had a negative impact on the mental health of women who were following a process of assisted reproduction treatment, increasing their levels of emotional distress and anxiety.
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Affiliation(s)
- Marta Correa Rancel
- Human Reproduction Unit, Gynecology Service, University Hospital of the Canary Islands, 38320 Tenerife, Spain; (M.C.R.); (E.S.C.); (Y.S.H.); (J.C.L.); (D.B.Q.)
- Departamento de Obstetricia-Ginecología, Pediatría, Preventiva, Medicina Legal y Forense, Microbiología, Parasitología, Universidad de la Laguna, 38200 Santa Cruz de Tenerife, Spain
| | - Elena Sosa Comino
- Human Reproduction Unit, Gynecology Service, University Hospital of the Canary Islands, 38320 Tenerife, Spain; (M.C.R.); (E.S.C.); (Y.S.H.); (J.C.L.); (D.B.Q.)
| | | | - Yaiza Suárez Hernández
- Human Reproduction Unit, Gynecology Service, University Hospital of the Canary Islands, 38320 Tenerife, Spain; (M.C.R.); (E.S.C.); (Y.S.H.); (J.C.L.); (D.B.Q.)
| | - Janet Carballo Lorenzo
- Human Reproduction Unit, Gynecology Service, University Hospital of the Canary Islands, 38320 Tenerife, Spain; (M.C.R.); (E.S.C.); (Y.S.H.); (J.C.L.); (D.B.Q.)
| | - Diego Gomez-Baya
- Department of Social, Developmental and Educational Psychology, Universidad de Huelva, 21007 Huelva, Spain;
| | - Delia Baez Quintana
- Human Reproduction Unit, Gynecology Service, University Hospital of the Canary Islands, 38320 Tenerife, Spain; (M.C.R.); (E.S.C.); (Y.S.H.); (J.C.L.); (D.B.Q.)
- Departamento de Obstetricia-Ginecología, Pediatría, Preventiva, Medicina Legal y Forense, Microbiología, Parasitología, Universidad de la Laguna, 38200 Santa Cruz de Tenerife, Spain
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Zaccardi F, Byrne K, Khunti K, Kloecker D, Reynoso R, Shabnam S, Vaz L, Yates T, Gillies C. The impact of COVID-19 lockdowns on the body mass index of people living with obesity: A UK retrospective cohort study using the UK Clinical Practice Research Datalink. Obes Res Clin Pract 2023; 17:468-476. [PMID: 37783586 DOI: 10.1016/j.orcp.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/24/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Restrictions implemented by governments during the coronavirus disease 2019 (COVID-19) pandemic affected people's eating habits and physical activity. We investigated the effect of COVID-19 lockdowns and restrictions on body mass index (BMI) and weight in a UK population, according to BMI class, sex, age and ethnicity. METHODS This retrospective observational cohort study used the Clinical Practice Research Datalink AURUM database. Baseline spanned from 22 March 2017-22 March 2020, and the follow-up lockdown period was from 23 March 2020 (start of the lockdown in the UK) to 13 March 2021. The descriptive analysis included individuals with ≥ 1 valid BMI/weight measurements during both the baseline and follow-up periods, while the model-based analysis comprised individuals with ≥ 1 valid measurement(s) during baseline. Results were stratified by baseline BMI category, sex, age and ethnicity. RESULTS In the descriptive analysis (n = 273,529), most individuals did not change BMI category post-lockdown (66.4-83.3%). A greater proportion of women (12.6%) than men (9.5%) moved up BMI categories post-lockdown. Compared with older groups, a higher proportion of individuals < 45 years old increased post-lockdown BMI category. The model-based analysis (n = 938,150) revealed consistent trends, where changes in body weight and BMI trajectories pre- and post-lockdown were observed for women and for individuals < 45 years. CONCLUSION During COVID-19 restrictions, women and young individuals were more likely than other groups to increase BMI category and weight post-lockdown.
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Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK.
| | | | - Kamlesh Khunti
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester Diabetes Centre, Leicester, UK; National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David Kloecker
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | - Sharmin Shabnam
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Luis Vaz
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Thomas Yates
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Clare Gillies
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK; Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
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Bolesławska I, Jagielski P, Błaszczyk-Bębenek E, Jagielska A, Przysławski J. Lifestyle Changes during the SARS-CoV-2 Pandemic as Predictors of BMI Changes among Men and Women in Poland. Nutrients 2023; 15:nu15112427. [PMID: 37299391 DOI: 10.3390/nu15112427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Social isolation during the SARS-CoV-2 pandemic affected people's body weight, therefore, this study was designed to evaluate the association between lifestyle elements and the change in BMI during lockdown. METHODS This retrospective observational study involved 290 questionnaires completed by adult participants divided into three groups according to BMI change during isolation. The structured questionnaire included a general description of the study objective and collected data regarding sociodemographics, anthropometrics, physical activity, sedentary behaviour, sleep duration, and food intake pre- and during COVID-19 lockdown. RESULTS A decrease or increase in BMI was found in 23.6% and 47.8% of women and 18.5% and 42.6% of men, respectively. Among those who lost weight, 46.5% of women and 40% of men followed a diet of their own choice, 30.2% of women and 25% of men changed their product mix and reduced their intake, 40% of men stopped eating outside the home. An increase in BMI was associated with increased food intake (32.2% of women and 28.3% of men), increased sleep duration on weekdays (49.2% of women and 43.5% of men) and, in more than 50% of subjects, decreased physical activity. In women, increased BMI was associated with the highest frequency of snacking (p = 0.0003), the highest intake of sweets (p = 0.0021), and in men with the highest intake of alcohol (p = 0.0017). CONCLUSIONS The observed changes in BMI during social isolation were the result of lifestyle modifications including dietary behaviour and differed by gender.
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Affiliation(s)
- Izabela Bolesławska
- Department of Bromatology, Poznan University of Medical Sciences, 3 Rokietnicka Street, 60-806 Poznan, Poland
| | - Paweł Jagielski
- Department of Nutrition and Drug Research, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, 8 Skawińska Street, 31-066 Kraków, Poland
| | - Ewa Błaszczyk-Bębenek
- Department of Nutrition and Drug Research, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, 8 Skawińska Street, 31-066 Kraków, Poland
| | - Anna Jagielska
- Department of Social Medicine and Public Health, Medical University of Warsaw, 3 Oczki Street, 02-007 Warsaw, Poland
| | - Juliusz Przysławski
- Department of Bromatology, Poznan University of Medical Sciences, 3 Rokietnicka Street, 60-806 Poznan, Poland
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Jaisamrarn U, Esteban-Habana MA, Padolina CS, Decena DCD, Dee MT, Damodaran P, Bhaskaran V, Garg V, Dorado E, Hu H. Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion. SAGE Open Med 2023; 11:20503121231173377. [PMID: 37223672 PMCID: PMC10201185 DOI: 10.1177/20503121231173377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/14/2023] [Indexed: 05/25/2023] Open
Abstract
Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals supplementation, education, and self-care from preconception to the first 1000 days of life, which warranted further attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception, pregnancy, and lactation stages was identified using literature databases. A pre-meeting survey was conducted to determine the current practices and challenges in Southeast Asia. Based on the literature review and clinical experience, experts defined the topics, and an online meeting was held on 13th July 2021. During the meeting, nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and prevention strategies for women in Southeast Asia. The recent pandemic further impacted nutrition status, pregnancy, and neonatal health outcomes. The expert panel emphasized a need to improve existing inadequacies in education, self-care, and social support, and discussed the role of policymakers in addressing the barriers to dietary changes. As inadequacies in regular vitamins and minerals supplementation, education, and self-care for women of reproductive age implicate maternal and child health outcomes, there is an urgent need for addressing malnutrition concerns in this population. Thus, a strong partnership between policymakers, healthcare professionals, and other relevant sectors is required.
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Affiliation(s)
- Unnop Jaisamrarn
- Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand
| | | | - Christia S Padolina
- University of the East Ramon Magsaysay
Memorial Medical Center, Quezon City, Philippines
| | | | - Marlyn T Dee
- UST Faculty of Medicine and Surgery,
Manila, Philippines
| | - Premitha Damodaran
- Pantai Hospital Kuala Lumpur, Wilayah
Persekutuan Kuala Lumpur, Malaysia
| | | | - Vandana Garg
- Haleon (formerly GSK Consumer
Healthcare), Singapore, Singapore
| | - Egbert Dorado
- Haleon (formerly GSK Consumer
Healthcare), Singapore, Singapore
| | - Henglong Hu
- Haleon (formerly GSK Consumer
Healthcare), Singapore, Singapore
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Cirillo M, Basile V, Mazzoli L, Coccia ME, Fatini C. Impact of COVID-19 Pandemic on Women's Health and Obstetric Outcomes after Assisted Reproduction: A Survey from an Italian Fertility Center. J Pers Med 2023; 13:jpm13030563. [PMID: 36983744 PMCID: PMC10059757 DOI: 10.3390/jpm13030563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND the restrictive measures that were adopted during three waves of the COVID-19 pandemic had an impact on both the emotional state and lifestyle of the general population. We evaluated the impact of COVID-19 pandemic on lifestyles and emotional states of women planning assisted reproductive technology (ART), and whether these changes affected ART outcomes. METHODS quantitative research, using a web-based survey, was performed on 289 Caucasian women. RESULTS In preconception, we observed higher percentage of women with positive obstetric outcomes who reduced body weight (52.4% vs. 27.2%, p = 0.09). Over 60% of women with positive outcomes practiced physical activity vs. 47% of women with negative outcomes (p = 0.03), as well as having better quality of sleep (45% vs. 35%), and a more solid relationships with their partners (65.1% vs. 51.7%, p = 0.03). Women who increased their intake of whole grains, fruits, vegetables, and legumes (p < 0.05), according to the Mediterranean diet, showed positive outcomes. We observed that participants who experienced "very much" or "extreme" anxiety, sadness, and fear (p < 0.05) during pandemic were clearly more numerous in the group with negative pregnancy outcomes. CONCLUSIONS healthy lifestyle together with a positive emotional state in preconception can positively influence the obstetric outcomes after ART.
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Affiliation(s)
- Michela Cirillo
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
- Centre for Assisted Reproductive Technology, Division of Obstetrics and Gynaecology, Careggi University Hospital, 50134 Florence, Italy
| | - Valentina Basile
- Centre for Assisted Reproductive Technology, Division of Obstetrics and Gynaecology, Careggi University Hospital, 50134 Florence, Italy
| | - Letizia Mazzoli
- Centre for Assisted Reproductive Technology, Division of Obstetrics and Gynaecology, Careggi University Hospital, 50134 Florence, Italy
| | - Maria Elisabetta Coccia
- Centre for Assisted Reproductive Technology, Division of Obstetrics and Gynaecology, Careggi University Hospital, 50134 Florence, Italy
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, 50134 Florence, Italy
| | - Cinzia Fatini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
- Centre for Assisted Reproductive Technology, Division of Obstetrics and Gynaecology, Careggi University Hospital, 50134 Florence, Italy
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Van Laren A, Drießen M, Rasa S, Massar K, Ten Hoor GA. Nutritional changes during the COVID-19 pandemic: a rapid scoping review on the impact of psychological factors. Int J Food Sci Nutr 2023; 74:124-187. [PMID: 36823035 DOI: 10.1080/09637486.2023.2180613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
COVID-19 and the resulting measures to curb the spread of the virus have significantly changed our lives, including our nutritional choices. In this rapid scoping review an overview is provided of what psychological factors may be associated with peoples' eating behaviour during COVID-19 restrictions. Relevant literature was identified using PubMed, PsycInfo, CINAHL and MEDLINE databases from 2019 onwards. For included studies, information on study characteristics, eating behaviours, and psychological factors were extracted. 118 articles were included, representing 30 countries. Findings indicated that most people consumed more and unhealthy food in times of COVID-19 restrictions, while some consumed less but often for the wrong reasons. Several psychological factors, related to (1) affective reactions, (2) anxiety, fear and worriers, (3) stress and (4) subjective and mental wellbeing were found to be associated with this increase in food consumption. These outcomes may help to be better inform future interventions, and with that, to be better prepared in case of future lockdown scenarios.
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Affiliation(s)
- Anthea Van Laren
- Department Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Mona Drießen
- Department Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Sophia Rasa
- Department Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Karlijn Massar
- Department Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Gill A Ten Hoor
- Department Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
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Rodino IS, Goedeke S, Oxlad M, Nowoweiski SJ. Physical and psychological wellbeing among Australian and New Zealand patients seeking fertility treatment during COVID-19. AUSTRALIAN PSYCHOLOGIST 2023. [DOI: 10.1080/00050067.2023.2172996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Iolanda S. Rodino
- Medical School, The University of Western Australia, Perth, Australia
| | - Sonja Goedeke
- Department of Psychology and Neuroscience, Auckland University of Technology, Auckland, New Zealand
| | - Melissa Oxlad
- School of Psychology, The University of Adelaide, Adelaide, Australia
| | - Sarah J. Nowoweiski
- Counselling Services Manager, Newlife IVF Suite 3, Box Hill North, Australia
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Pappa K, Xydias EM, Ziogas AC, Bimba K, Tsakos E, Kolibianakis E. The Impact of Coronavirus Disease 2019 Pandemic on Female Patients Seeking or Undergoing Fertility Treatment in a Single In vitro Fertilisation Clinic in Greece: An International, Cross-sectional Study. J Hum Reprod Sci 2023; 16:50-56. [PMID: 37305776 PMCID: PMC10256943 DOI: 10.4103/jhrs.jhrs_11_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 06/13/2023] Open
Abstract
Background The temporary delay in fertility treatments due to the coronavirus disease 2019 (COVID-19) pandemic, in combination with the imposed lockdowns, has created psychological distress and anxiety amongst infertile patients. Aims The aim of this study was to evaluate how the pandemic has influenced assisted reproduction technology (ART) patients in Greece, during the second wave of the pandemic. An additional aim was to examine the effects of the pandemic on cross-border patients in particular, compared to national ones. Settings and Design This study was a cross-sectional, questionnaire-based study, distributed to 409 patients of a single in vitro fertilisation (IVF) clinic in Greece, during the period between January until the end of April 2021. Materials and Methods The survey was conducted online via E-mail and was distributed to national and international female patients of a single IVF clinic in Greece, who were undergoing ART treatment during the second wave of the COVID-19 pandemic. Patient participation was anonymous, and participants provided informed consent for collection and publication of data. Statistical Analysis Used The mean values of baseline characteristics, along with answer percentages per questionnaire item, were calculated. Collected data were cross-tabulated, and the Chi-square test was used as a measurement of the differences between national and cross-border patients. A P value lower than 0.05 was considered statistically significant. All analyses were conducted using the SPSS Statistics software. Results From 409 initial candidates, 106 women, with a mean age of 41.2 years, completed the questionnaire (26% response rate). The majority of national patients did not experience any delays in their fertility plans (62%), while cross-border patients experienced over 6 months of delays (54.7%). The main reason for fertility postponement was travel restrictions due to COVID-19 for cross-border patients (62.5%), while national patients cited additional reasons. The majority of patients experienced a degree of stress (65.2%) due to the delays, however were not fearful of COVID-19 infection (54.7%). Most patients were aware of the protective measures taken by IVF clinics (80.2%), and this was a determinant factor (71.7%) for their decision to restart their fertility treatment. Conclusion The COVID-19 pandemic lockdowns had a significant emotional impact on patient receiving or undergoing ART treatment in Greece. This impact was more pronounced on cross-border patients. This highlights the need for continuation of ART care, with the appropriate protective measures, during the pandemic, as well as during similar times of crisis in the future.
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Affiliation(s)
| | - Emmanouil M. Xydias
- Embryo Clinic IVF, Thessaloniki, Greece
- Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Apostolos C. Ziogas
- Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | | | - Efstratios Kolibianakis
- First Department of Obstetrics and Gynecology, Unit of Human Reproduction, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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11
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Irani M, Bashtian MH, Soltani N, Khabiri F. Impact of COVID-19 on mental health of infertile couple: A rapid systematic review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:404. [PMID: 36824404 PMCID: PMC9942163 DOI: 10.4103/jehp.jehp_1655_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/05/2022] [Indexed: 06/18/2023]
Abstract
Infertile couples experience a lot of psychological stress due to the inability to achieve the desired social role. Couples who decide to continue assisted reproductive therapy (ART) during the epidemic also experience the psychological impact of the COVID-19 epidemic, which affects their daily lives due to social isolation, quarantine, travel restrictions, and cancellation of treatment. Therefore, the purpose of this study was to assess the mental health of infertile couple pausing or delaying their treatment due to the COVID-19 pandemic. PubMed, Scopus, Cochrane, Embase, Web of Science, ScienceDirect, Google Scholar, Research Gate, and the World Health Organization databases and websites were systematically searched for original studies concerning abortion in the era of COVID-19 pandemic published by August 15, 2021. We used the following keywords: "COVID-19 Corona virus, infertility, reproductive technique, fertilization, assisted reproduction, pregnant termination, psychological, in vitro mental status, depressive symptoms, and anxiety." In sum, after automatically and manually search and excluding duplicates, 269 articles were found. In final, after screening, 18 articles were selected. Most patients experienced negative emotions during the COVID-19 epidemic. When reproductive services were re-established, participants showed higher levels of anxiety and lower quality of life than before quarantine. Women who thought pregnancy was more important than getting COVID-19 had higher levels of anxiety than women who thought otherwise (P < 0.05). The COVID-19 pandemic has negative impacts on the mental health and quality of life of patients seeking fertility services and coping with it requires timely and appropriate psychological intervention, accurate information, and social and organizational support.
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Affiliation(s)
- Morvarid Irani
- Department of Midwifery, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
- Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Maryam Hassanzadeh Bashtian
- Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
- Department of Midwifery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Narges Soltani
- Department of Midwifery, School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran
| | - Fatemeh Khabiri
- Department of Midwifery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
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Horibe Y, Nakabayashi A, Murata S, Hashimoto T, Tabata T. COVID-19 infection control protocol and acceptance in an ART in vitro fertilization hospital. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2022; 27:19. [PMID: 35855738 PMCID: PMC9281231 DOI: 10.1186/s43043-022-00112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/06/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose In Tokyo, where the highest coronavirus disease 2019 (COVID-19) infection rates have been reported nationally, we introduced and performed polymerase chain reaction (PCR) testing on the patients prior to them coming for oocyte retrieval (OR) or embryo transfer (ET) procedures. In addition, we recommended that patients self-inject ovarian stimulation drugs to reduce the number of hospital visits required. We aimed to assess the patient acceptance of these measures and the change of treatment number. Methods We conducted a retrospective study examining the patients coming for OR or ET, from the first time a state of emergency was declared in Japan, May 2020, until September 2021. Results A total of 79 out of 94 (94%) patients complied with the measures. This may reflect that PCR universal screening was accepted by most patients as necessary for reducing infection spread. In addition, the number of patients receiving OR and ET increased. The widespread adoption of work-from-home practices during the pandemic has made outpatient visits more acceptable to the general public. Conclusions Universal screening and self-injection are accepted and effective infection measures in patients presenting for OR and ET.
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Shahabi N, Hosseini Z, Homayuni A, Ezati Rad R, Gharibzadeh A. Explaining the factors affecting women's life during COVID‐19 lockdown: A qualitative study among women in Southern Iran. Health Sci Rep 2022; 5:e957. [PMCID: PMC9686351 DOI: 10.1002/hsr2.957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/26/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Nahid Shahabi
- Student Research Committee, Faculty of Health Hormozgan University of Medical Sciences Bandar Abbas Iran
| | - Zahra Hosseini
- Tobacco and Health Research Center Hormozgan university of Medical Sciences Bandar abbas Iran
| | - Atefeh Homayuni
- Student Research Committee, Faculty of Health Hormozgan University of Medical Sciences Bandar Abbas Iran
| | - Roghayeh Ezati Rad
- Student Research Committee, Faculty of Health Hormozgan University of Medical Sciences Bandar Abbas Iran
| | - Abdollah Gharibzadeh
- Tobacco and Health Research Center Hormozgan university of Medical Sciences Bandar abbas Iran
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Kikuchi K, Islam R, Nishikitani M, Sato Y, Izukura R, Yokota F, Khan NJ, Nessa M, Ahmed A, Morokuma S, Nakashima N. Women’s health status before and during the COVID-19 pandemic in rural Bangladesh: A prospective longitudinal study. PLoS One 2022; 17:e0266141. [PMID: 35560141 PMCID: PMC9106176 DOI: 10.1371/journal.pone.0266141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/15/2022] [Indexed: 11/19/2022] Open
Abstract
The coronavirus disease (COVID-19) pandemic has widely spread worldwide since 2020. Several countries have imposed lockdown or stay-at-home policies to prevent the infection. Bangladesh experienced a lockdown from March 2020 to May 2020, and internal travel was restricted. Such long and strict confinement may impact women’s health. Herein, we aimed to assess the impact of the COVID-19 pandemic on women’s health by comparing their health status before and during the pandemic. We conducted a prospective longitudinal study in two zones in the Chhaygaon union, rural district Shariatpur, Bangladesh. The study population comprised non-pregnant women aged 15–49 years. We visited the household of all eligible women and invited them for health checkups. The survey staff examined their health status at the checkup camps and conducted questionnaire interviews. In total, 121 non-pregnant women received health checkups both from June 2019 to July 2019 and in October 2020, before and during the COVID-19 pandemic, respectively. Compared with those during the 2019 health checkup, the medians of body mass index, systolic blood pressure, and diastolic blood pressure were significantly higher (22.7 kg/m2 to 23.6 kg/m2; 110.0 mmHg to 111.0 mmHg; and 73.0 mmHg to 75.0 mmHg, respectively, p<0.05) during the 2020 health checkup. In contrast, urine glucose levels were significantly lower (10.1% to 3.4%, p = 0.021). The lack of physical activity and other inconvenience accumulation caused by the prolonged confinement might have affected their health status. This necessitates local health workers to promote physical activity to prevent health deterioration during the pandemic.
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Affiliation(s)
- Kimiyo Kikuchi
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
- * E-mail:
| | - Rafiqul Islam
- Medical Information Center, Kyushu University Hospital, Maidashi, Higashi-ku, Fukuoka, Japan
- Global Communication Center, Grameen Communications, Mirpur, Dhaka, Bangladesh
| | - Mariko Nishikitani
- Medical Information Center, Kyushu University Hospital, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoko Sato
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
- Division of Integrated Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minami-ku, Hiroshima, Japan
| | - Rieko Izukura
- Social Medicine, Department of Basic Medicine, Faculty of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Fumihiko Yokota
- Institute for Asian and Oceanian Studies, Kyushu University, Motooka, Nishi-ku, Fukuoka, Japan
| | - Nusrat Jahan Khan
- Global Communication Center, Grameen Communications, Mirpur, Dhaka, Bangladesh
| | - Meherun Nessa
- Holy Family Red Crescent Medical College & Hospital, Dhaka, Bangladesh
| | - Ashir Ahmed
- Department of Information Science and Technology, Faculty of Information Science and Electrical Engineering, Kyushu University, Fukuoka, Japan
| | - Seiichi Morokuma
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Naoki Nakashima
- Medical Information Center, Kyushu University Hospital, Maidashi, Higashi-ku, Fukuoka, Japan
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The Impact of Lockdowns on Caffeine Consumption: A Systematic Review of the Evidence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095255. [PMID: 35564647 PMCID: PMC9102419 DOI: 10.3390/ijerph19095255] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 01/13/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) has been characterized by the World Health Organization as a pandemic in March 2020 and the lockdown measures that were implemented in an effort to limit the transmission of the virus affected the daily life of many people in all over the world. The aim of this systematic review was to investigate the changes during/after the lockdowns in caffeine consumption by coffee and energy drinks. A systematic literature search was conducted in three databases (PubMed, Embase, Web of Science) up to 31 December 2021 and out of 19,511 studies found and 12,885 screened, 16 studies were included according to eligibility criteria. Results regarding coffee consumption showed that a significant part of individuals decreased their consumption and in five studies an increase was reported, including women and seniors >60 years old. Energy drinks were also consumed less during the lockdown compared to the pre-lockdown time. Attention should be given for menopausal women where an increase in coffee consumption was found which could impair bone density, but further research is needed in order to make safe conclusions.
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Delamuta LC, Monteleone PA, Ferreira-Filho ES, Heinrich-Oliveira V, Soares-Júnior JM, Baracat EC, Maciel GA. Coronavirus Disease 2019 and Human Reproduction: A Changing Perspective. Clinics (Sao Paulo) 2021; 76:e3032. [PMID: 34495081 PMCID: PMC8395373 DOI: 10.6061/clinics/2021/e3032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022] Open
Abstract
Since the outbreak of severe acute respiratory coronavirus 2 (SARS-CoV-2), the coronavirus disease 2019 has had a wide range of effects on human health. This paper summarizes the data related to the effects of the SARS-CoV-2 infection on human reproduction. Both the male and female reproductive tract express high levels of receptors and proteins needed for viral cell entry. There is presently no evidence that gametes are affected by the infection. Male fertility may be temporarily reduced due to inflammatory responses following infection. The endometrium is highly susceptible to SARS-CoV-2 cell entry; however, it remains unclear whether this could alter receptivity and embryo implantation. Menstrual cycle changes were reported in women who experienced severe infection; however, they tended to be reversible. For couples undergoing assisted reproduction treatment, the pandemic led to a significant psychological burden, with changes in lifestyle that could directly affect the success of the treatment. Human reproduction societies recommend screening all patients prior to cycle initiation and avoiding treatment of women with severe comorbidities until the pandemic is under control. Finally, for pregnant women, it is expected that the infection is more severe in women in the third trimester and in those with comorbidities. Those who are symptomatic for SARS-CoV-2 are more likely to have increased rates of prematurity and intrapartum fetal distress than those who are asymptomatic. Vertical transmission cannot be completely ruled out, but neonatal infection rates are low. Vaccination appears to be safe and is indicated for use in pregnant and lactating women because the benefits outweigh the risks.
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Affiliation(s)
| | | | | | | | | | | | - Gustavo A.R. Maciel
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Biviá-Roig G, Boldó-Roda A, Blasco-Sanz R, Serrano-Raya L, DelaFuente-Díez E, Múzquiz-Barberá P, Lisón JF. Impact of the COVID-19 Pandemic on the Lifestyles and Quality of Life of Women With Fertility Problems: A Cross-Sectional Study. Front Public Health 2021; 9:686115. [PMID: 34350151 PMCID: PMC8326371 DOI: 10.3389/fpubh.2021.686115] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 01/18/2023] Open
Abstract
Background: The COVID-19 pandemic has implied worldwide the imposition of confinement measures and mobility restrictions, to a greater or lesser extent. It has also meant the closure of some public medical services such as reproductive care. This situation may have impacted the health-related behaviour and quality of life of women with fertility problems. Objective: The objective of this study was to analyse the effects of confinement and the suspension of reproductive medical care on the lifestyle (diet, physical exercise, and smoking habits), anxiety and depression, and quality of life of infertile women by comparing their pre- and post-confinement situations. Methods: We carried out a cross-sectional, internet-based study. Information was collected on these women's adherence to the Mediterranean diet (MEDAS questionnaire), physical exercise (IPAQ-SF), anxiety and depression (HADS), and quality of life related to fertility (FertiQol) before, during, and after confinement. The survey was conducted between 1 September and 28 October 2020. Results: A total of 85 women participated. There had been a significant increase in anxiety and depression levels (P < 0.001) and an increase in tobacco consumption among female smokers during confinement vs. pre-confinement (62.5% had increased their consumption). The participants had also increased the mean number of hours they spent sitting (P < 0.001). There had also been an increase in vigorous and moderate exercise levels by 40 and 30%, respectively (P = 0.004). However, no differences were observed in these patients' eating habits as a result of confinement (P = 0.416). When the reproduction service was resumed, the participants showed higher anxiety level scores (P = 0.001) with respect to the pre-confinement situation as well as lower mean FertiQol scale score (P = 0.008). Conclusions: Confinement had increased anxiety and depression levels among these infertile women as well as tobacco use among the participants who were smokers. The prolonged closure of reproductive care units decreased the quality of life of the participants of this study. These results suggest the need to implement online programs to improve healthy habits and quality of life of this population group.
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Affiliation(s)
- Gemma Biviá-Roig
- Department of Nursing and Physiotherapy, Faculty of Health Sciences, University CEU-Cardenal Herrera, CEU Universities, Valencia, Spain
| | - Ana Boldó-Roda
- Department of Gynecology and Obstetricia, La Plana University Hospital, Vila-Real, Spain
| | - Ruth Blasco-Sanz
- Department of Gynecology and Obstetricia, La Plana University Hospital, Vila-Real, Spain
| | - Lola Serrano-Raya
- Department of Nursing and Physiotherapy, Faculty of Health Sciences, University CEU-Cardenal Herrera, CEU Universities, Valencia, Spain.,Department of Gynecology and Obstetricia, Hospital of Sagunto, Valencia, Spain
| | | | - Pedro Múzquiz-Barberá
- Department of Nursing and Physiotherapy, Faculty of Health Sciences, University CEU-Cardenal Herrera, CEU Universities, Valencia, Spain
| | - Juan Francisco Lisón
- Department of Biomedical Sciences, Faculty of Health Sciences, University CEU-Cardenal Herrera, CEU Universities, Valencia, Spain.,CIBER of Physiopathology of Obesity and Nutrition CIBERobn, Carlos III Health Institute, Madrid, Spain
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Kirubarajan A, Patel P, Tsang J, Prethipan T, Sreeram P, Sierra S. The psychological impact of the COVID-19 pandemic on fertility care: a qualitative systematic review. HUM FERTIL 2021:1-8. [PMID: 34114919 DOI: 10.1080/14647273.2021.1938245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this systematic review was to characterise psychological impacts of the COVID-19 pandemic related to fertility care. We conducted a systematic search following PRISMA guidelines of five databases (EMBASE, Medline-OVID, CINAHL, Web of Science, and PsycINFO) from March 17th 2020 to April 10th 2021. Citing articles were also hand-searched using Scopus. Of the 296 original citations, we included fifteen studies that encompassed 5,851 patients seeking fertility care. Eleven studies only included female participants, while four included both male and female participants. The fifteen studies unanimously concluded that the COVID-19 pandemic caused negative psychological impacts on fertility care. Risk factors included female sex, single marital state, previous ART failure, prior diagnoses of anxiety or depression, and length of time trying to conceive. Specific concerns included the worry and frustration of clinic closure, concerns about pregnancy and COVID-19 infection, and advancing age. There were contrasting beliefs on whether the decision to stop fertility treatments during the COVID-19 pandemic was justified. In addition, we found that many patients preferred to resume fertility treatment, despite anxieties regarding the risk of the COVID-19 virus. We recommend that fertility providers screen patients for risk factors for poor mental health and tailor support for virtual care.
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Affiliation(s)
- Abirami Kirubarajan
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Priyanka Patel
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada
| | - Jackie Tsang
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Padmaja Sreeram
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Sony Sierra
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada
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