Threatened abortion, threatened premature labor, and preterm birth during the first state of emergency for COVID-19 in 2020 in Japan

The association of COVID-19 lockdowns with adverse birth and pregnancy outcomes in 28 high-income countries: a systematic review and meta-analysis

We conducted a systematic review and meta-analysis to review the association of lockdowns with adverse birth and pregnancy outcomes (ABPOs) and related inequalities, in high-income countries (HICs). Databases (EMBASE, MEDLINE/PubMed and Web of Science) were searched from 1 January 2019 to 22 June 2023 for original observational studies based in HICs that compared the rates of ABPOs, before and during lockdowns. The risk of bias was assessed using the Newcastle-Ottawa tool for cohort studies. We ran random-effects meta-analyses and subgroup analyses per region, lockdown period, ethnicity group and deprivation level and adjusted for underlying temporal trends. A total of 132 studies were meta-analysed from 28 HICs. Reduced rates of preterm birth (reported by 26 studies) were associated with the first lockdown (relative risk 0.96, 95% confidence interval 0.93-0.99), 11 studies adjusted for long-term trends and the association remained (0.97, 0.95-0.99), and subgroup analysis found that this association varied by continental region. Ten studies reported positive screening rates for possible depression antenatally, and lockdown was associated with increases in positive screening rates (1.37, 1.06-1.78). No other ABPOs were associated with lockdowns. Investigation of inequalities was limited due to data availability and heterogeneity; further research is warranted on the effect of lockdowns on health inequalities. This study was funded by the National Institute of Health Research, School of Primary Care Research and registered on PROSPERO (CRD42022327448).

Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach

BACKGROUND AND OBJECTIVE

It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan.

METHODS

A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus.

RESULTS

Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion.

CONCLUSION

These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.

Effects of the COVID-19 pandemic on the rates of adverse birth outcomes and fetal mortality in Japan: an analysis of national data from 2010 to 2022

BACKGROUND

Although the coronavirus disease 2019 (COVID-19) pandemic affected trends of multiple health outcomes in Japan, there is a paucity of studies investigating the effect of the pandemic on adverse birth outcomes and fetal mortality. This study aimed to investigate the effect of the onset of the pandemic on the trends in adverse birth outcomes and fetal mortality using national data in Japan.

METHODS

We used the 2010-2022 birth and fetal mortality data from the Vital Statistics in Japan. We defined the starting time of the effect of the pandemic as April 2020, and the period from January 2010 to March 2020 and that from April 2020 to December 2022 were defined as the pre- and post- pandemic period, respectively. The rates of preterm birth, term low birth weight (TLBW), small-for-gestational-age (SGA), large-for-gestational-age (LGA), spontaneous fetal mortality, and artificial fetal mortality were used as outcomes. An interrupted time series analysis was conducted using monthly time series data of the outcomes to evaluate the effects of the pandemic. In addition, a modified Poisson regression model was used to evaluate the effects of the pandemic on these outcomes using individual-level data, and the adjusted risk ratio of the effect was calculated.

RESULTS

The adverse birth and fetal mortality outcomes showed a decreasing trend over the years, except for preterm birth and LGA birth rates, and SGA birth rates tended to reach their lowest values after the onset of the pandemic. The interrupted time series analysis revealed that the pandemic decreased preterm birth, TLBW, and SGA birth rates. In addition, the regression analysis revealed that the pandemic decreased the TLBW, SGA, and artificial fetal mortality rates.

CONCLUSIONS

Analyses performed using national data suggested that the pandemic decreased the TLBW and SGA rates in Japan.

Mother-to-infant bonding difficulties are associated with future maternal depression and child-maltreatment behaviors: A Japanese nationwide longitudinal study

BACKGROUND

Mother-to-infant bonding difficulties (MIBD) are considered risk factors for postpartum depression and child-maltreatment behaviors. However, few longitudinal studies have examined this hypothesis. This study aims to explore the relationship between MIBD and subsequent maternal depression and child-maltreatment behaviors using longitudinal data from a 2021 Japanese nationwide survey.

METHODS

We studied 658 first-time mothers who had given birth within the past year and had not reported postpartum depression or child-maltreatment behaviors at baseline. The Japanese version of Mother-to-Infant Bonding Scale (MIBS) was used to measure MIBD. Subjects were monitored for six months and subsequently completed the Edinburgh Postnatal Depression Scale and responded to inquiries about child-maltreatment behaviors.

RESULTS

After adjusting for covariates, MIBD was associated with higher odds of maternal depression (OR=1.737, 95 % CI [1.078, 2.797]) and child-maltreatment behaviors (OR=2.040, 95 % CI [1.401, 2.970]) six months later. Further analysis indicated that MIBD was particularly associated with a heightened risk of emotional abuse (OR=2.172, 95 % CI [1.486, 3.176]). Sensitivity analysis confirmed these findings through multiple approaches, such as applying inverse probability weighting to mitigate selection bias, using an alternative MIBS cutoff score of 5, and adopting a time-varying model to account for the dynamic nature of depressive symptoms and child-maltreatment behaviors.

CONCLUSION

Proactive screening for MIBD could serve as a valuable tool in the early detection of maternal depression and potential child-maltreatment behaviors.

The COVID-19 pandemic affects pregnancy complications and delivery outcomes in Japan: a large-scale nationwide population-based longitudinal study

The impact of the coronavirus disease 2019 (COVID-19) pandemic on pregnancy outcomes in Japan at the national level is unclear. This study aimed to assess the impact of the pandemic on pregnancy complications and delivery outcomes in Japan using nationwide population-based longitudinal data. Secondary data from the Japan Society of Obstetrics and Gynecology from 2016 to 2020 were analyzed. Obstetric information, pregnancy complications, and delivery information of pregnant women over 22 weeks of gestation were compared before and during the pandemic. The trends of hypertensive disorder of pregnancy, fetal growth restriction, and APGAR < 7 increased, whereas those of preterm birth and low birth weight decreased during the COVID-19 pandemic. Pregnancy complications and delivery outcomes have worsened during the COVID-19 pandemic in Japan. Social changes caused by unprecedented situations may have massively influenced pregnancy in several ways. Our findings suggest that even in mild lockdowns like those in Japan, the introduction of social fear during the pandemic might negatively impact pregnancy outcomes.

The prevalence and risk factors of suicidal ideation in women with and without postpartum depression

AIM

Suicidal ideation (SI) is a severe mental health issue in the postpartum period. As depression is a major risk factor of SI, it is often considered that the risk factors of SI are the same as those of postpartum depression. However, SI occurs in women without postpartum depression as well. The aim of this study is to separately examine the prevalence and risk factors of SI in postpartum women with and without depression.

METHODS

We used data of 5688 postpartum women from a 2021 Japanese nation-wide survey, whose age and geographical distributions were nationally representative. Postpartum depression was evaluated with the Edinburgh Postnatal Depression Scale (EPDS) and SI was measured with the 10th item of EPDS.

RESULTS

The prevalence of SI in women with and without depression (EPDS≥9) was 51.8 % and 3.3 %, respectively. Younger age and low family support were risk factors common to both women with and without depression. Being single, currently working, history of depressive disorders, and family members' visits to support being cancelled were risk factors of SI for women with depression. In contrast, primipara, history of psychiatric disorders other than depressive disorders, infectious disease other than colds during pregnancy, and feeling of loneliness increased since COVID-19 were risk factor of SI for women without depression.

CONCLUSION

Although with a low prevalence, SI occurs in women without postpartum depression, which has unique risk factors indicating distinct psychopathological mechanisms. These findings call for tailored SI intervention strategies according to whether postpartum depression is present or not.

The diagnostic accuracy of the Edinburgh Postnatal Depression Scale without the self-harm item

The Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used screening tool for perinatal depression. However, the 10th item of the EPDS intended to evaluate suicide ideation does not accurately capture suicide ideation and may cause psychological distress. Whereas endorsement of the strongest agreement "yes, quite often" on this item may be associated with suicide ideation, the response on this frequency is perfectly predicted by the EPDS full score. The discard of this item, therefore, is preferred. In the current study, using data from a nation-wide internet survey conducted in Japanese postpartum (n = 5688) and pregnant women (n = 1639), we show that the EPDS-9 without the 10th item correlates perfectly with the full EPDS or EPDS-10. Furthermore, the EPDS-9 and EPDS-10 have equivalent performance in differentiating participants' self-reported depression diagnosis as well as Kessler Psychological Distress Scale (K6)-based screening of depression. Lastly, at the cutoff of 9, the EPDS-9 performs well in predicting participants' response on the 10th item of EPDS; specifically, the sensitivity of differentiating frequent thoughts of self-harm is 0.968 and 1 in postpartum and pregnant women, respectively. Therefore, the EPDS-9 performs equivalently to EPDS-10 and can be considered to replace EPDS-10 in future use.

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.

Maternal heated tobacco product use during pregnancy and allergy in offspring

BACKGROUND

Little is known about the association between maternal use of heated tobacco products (HTPs) during pregnancy and the onset of allergy among offspring. This study aimed to determine whether maternal HTP smoking is associated with allergy in their offspring and to evaluate the potential dose-response association.

METHODS

In this web-based, cross-sectional survey conducted in July and August 2021 in Japan, we investigated 5688 pairs of postpartum women and infants (<3 years). Clinical diagnoses of infant asthma, rhinitis, conjunctivitis, or atopic dermatitis were reported. Using multilevel Poisson regression, we estimated the prevalence ratios (PRs) and 95% confidence intervals (CIs) of allergy in infants with HTP smoking categories cross-classified by pregnancy periods, and adjusted for potential covariates including maternal cigarette smoking and partner's smoking status. Non-smokers served as the reference group.

RESULTS

In total, 2.4% women smoked HTPs during pregnancy. Allergy occurred in 7.8% of the infants. The prevalence of allergy increased among the offspring of current HTP smokers during pregnancy at 15.2% (PR = 1.98, 95% CI 1.28-3.05); this association was the most pronounced during the first trimester but attenuated before pregnancy and postpartum. Dose-response associations were observed, for example a one-unit increase in daily maternal HTP use during pregnancy was associated with a 5% increase in allergy onset. Sub-group analyses excluding cigarette smokers during pregnancy and sensitivity analyses using the International Study of Asthma and Allergies in Childhood questionnaire showed a similar pattern.

CONCLUSIONS

Maternal HTP smoking during pregnancy is associated with allergy in the offspring.

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.

Amelioration of prevalence of threatened preterm labor during the COVID-19 pandemic: nationwide database analysis in Japan

We aimed to evaluate the changes in maternal and neonatal complications such as threatened preterm labor (TPL) and preterm birth before and during the coronavirus disease 2019 (COVID-19) pandemic using large-scale real-world data in Japan. We obtained data from the Japan Medical Data Center claims database and evaluated differences in maternal and neonatal complications, such as the prevalence of TPL and preterm birth before the COVID-19 pandemic (in the year 2018 or 2019) and during the COVID-19 pandemic (in 2020). We included 5533, 6257, and 5956 deliveries in the years 2018, 2019, and 2020, respectively. TPL prevalence and preterm birth had significantly decreased in 2020 (41.3%, 2.6%, respectively) compared with those reported in 2018 (45.3%, 3.9%, respectively) and 2019 (44.5%, 3.8%, respectively). Neonatal outcomes such as low-birth-weight infants and retinopathy of prematurity were also improved during the pandemic. There were no clear trends in the prevalence of maternal complications such as hypertensive disorders of pregnancy; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; and preeclampsia. Oral ritodrine hydrochloride usage in all participants had significantly decreased during the COVID-19 pandemic. In conclusion, our results suggest that the COVID-19 pandemic has ameliorated TPL and consequently reduced the number of preterm births.

Influence of the COVID-19 pandemic on breastfeeding support for healthy mothers and the association between compliance with WHO recommendations for breastfeeding support and exclusive breastfeeding in Japan

Background

Professional breastfeeding support contributes to maternal and child health. However, the influence of the current coronavirus disease 2019 (COVID-19) pandemic on breastfeeding support has not been carefully examined. Therefore, we assessed maternal breastfeeding intention and professional breastfeeding support before and during the pandemic. We further examined the association of compliance with World Health Organization (WHO) recommendations for professional breastfeeding support with exclusive breastfeeding during the pandemic.

Methods

This cross-sectional, internet-based, questionnaire study analyzed data from 484 healthy women with live singleton births between 15 October 2019 and 25 October 2020 in Japan. A delivery before 5 March 2020 was classified as a before-pandemic delivery (n = 135), and a delivery after 6 March 2020 was a during-pandemic delivery (n = 349). Among the ten breastfeeding support steps recommended by the WHO, we assessed the five steps that are measurable by maternal self-report and would likely exhibit variability. Receipt of a free formula sample or invitation to a free sample campaign by the time of survey was also asked. Infant feeding status at the time of the survey was measured among women with infants younger than 5 months, which was a subgroup of mothers who delivered during the pandemic. Mothers were asked what was given to infants during the 24 h before the survey and when nothing other than breast milk was given, the status was classified as exclusive breastfeeding.

Results

While 82.2% of women with a delivery before the pandemic intended to breastfeed, the rate was 75.6% during the pandemic (p = 0.120). The average number of breastfeeding support steps received was 3.24 before the pandemic but it was 3.01 during the pandemic (p = 0.069). In particular, rooming-in was less frequent (39.3% before vs. 27.8% during the pandemic, p = 0.014). Among mothers with infants younger than 5 months who had a delivery during the pandemic (n = 189), only 37.0% (n = 70) reported exclusively breastfeeding during the 24 h before completing the survey. Multiple logistic regression analysis indicated that receiving support for all five steps was positively associated with exclusive breastfeeding during the 24 h before the survey (adjusted odds ratio 4.51; 95% CI [1.50-13.61]). Receipt of a free formula sample or invitation to a free sample campaign was negatively associated with exclusive breastfeeding (adjusted odds ratio 0.43; 95% CI [0.19-0.98]). Other factors related to non-exclusive breastfeeding were older maternal age, lower education level, primiparity, and no breastfeeding intention.

Conclusions

The pandemic weakened breastfeeding support for healthy women in Japan; however, support practice that adhered to WHO recommendations appeared to be effective during the pandemic.