The effect of the Covid pandemic and lockdown on stillbirth rates in a South Indian perinatal centre

Introduction

The Covid-19 pandemic saw an increase in stillbirths across the world. The progress made for reducing stillbirth rates seemed to have been halted, reversed in many countries as all the available resources were targeted to save people from the Covid-19 pandemic. Stillbirth rates have been reported in various reports to have increased by 20–30% [1, 2].

India had the first wave in the year 2020 and a much severe second wave a year later in 2021. The first wave overwhelmed the healthcare capacity, but the second wave was unprecedented, chaotic with people dying in massive numbers. Reaching a healthcare facility, getting oxygen became a luxury, many dying for lack of medical care. Data has been coming in about obstetric mortality and morbidity with Covid infected women for the first and second wave in India [3]. The impact of the second wave was much worse when we consider the numbers infected, positivity rates and deaths; maximum daily numbers were more than 4 times. This is only a tip of the iceberg. Women without Covid-19 also suffered [4].

The major difference between the two pandemic waves was the healthcare access during lockdown, containment, and control measures for Covid-19. A very strict curfew with only emergency services in hospitals, all non-emergency healthcare was halted during the first wave. The second wave lockdown allowed healthcare related activities completely. Non-urgent care, planned visits and investigations were not interrupted. The two pandemic peaks with their contrast in containment policies allow an opportunity to explore positive and negative factors [5, 6]. The comparison of the impact of Covid-19 on stillbirths of first and second waves has not been reported. This study was done to study the effect of the Covid-19 pandemic on stillbirth rates in a tertiary perinatal unit in the southern part of India in the first and second wave.

Methods

Results

The year of first wave 2020 had 9,632 births in 12 months and 6,515 births from January to September 2021 (nine months) with a monthly average of 802 vs. 723 births, respectively. The new antenatal registration numbers were 16,577 in the first wave vs. 13,610 in the second wave, which gave a monthly average as 1,381 vs. 1512 respectively. The total antenatal clinic numbers were 95,837 and 83,981 with a monthly average of 7,986 vs. 9,331 in the first and second wave respectively. Table 1 shows the total numbers and monthly obstetric workload in these time periods. The total number of Covid positive cases were almost double in the second wave when compared to the first wave; 169 vs. 342 (p<0.01) with the same testing policy in the first and second wave of pandemic. Covid RT PCR was done for women with Covid-19 symptoms and did not do routine screening.

Figure 1 shows the flow chart of data exclusions. Multifetal births were excluded from each group, totalling 291 in the first wave and 212 in the second wave. The booked singleton births were 9,251 and 6,228 respectively. The maternal and fetal characteristics of these women are listed in Table 2.

Figure 1:

Flow chart of data analysis.

Figure 2 was created using monthly numbers from January 2020 to September 2021 and matching them with the daily Covid numbers in India, the first and second pandemic waves [9]. The first lockdown brought down the monthly obstetric clinic numbers from 10,477 in January 2020 to 3,506 in April 2020, a reduction of 66.5% in antenatal checks. The trends slowly increased to reach January 2020 levels only after 18 months in September 2021. The number of women registering for their first antenatal care visit also went down from 1,658 to 383 from January to April 2020, which was 77.1% reduction in registrations for antenatal care. The largest amount of births in a month was 977 in September 2021 and the smallest was 587 in March 2021, a reduction of 40.0%. The troughs due to the first wave of antenatal clinic numbers reached back to pre-pandemic levels only with the decline of the second wave. There was a decrease in antenatal clinic numbers due to fear of Covid-19 even before the lockdown in the first wave. The monthly trends of stillbirths showed an increase in February and June 2020, to seven per month, which was not found in any other month. There was no stillbirths in the interval between (April and May 2020) when there was maximum restriction of movement (Figure 2). The fear of infection, fall in antenatal clinic numbers and the increase in stillbirths was observed before the lockdown, not correlating with the peak of the first wave (Covid-19 daily cases). There were no stillbirths in the lockdown period coinciding with the travel restrictions and suspension of non-emergency healthcare services. The lifting up of the lockdown allowed women to reach for medical care and hence stillbirth numbers are high in June 2020. The second wave did not have an increase in stillbirth numbers, even though the Covid infection cases many times higher.

Figure 2:

Monthly trends in obstetric antenatal clinic numbers, stillbirths and daily Covid cases.

AN registrations = antenatal registrations represented number of first time booking for antenatal care. The yellow shaded area represents the first lockdown and the pink shaded zone for the second lockdown time. Daily Covid 19 cases for India graph were taken from John Hopkins University CSSE Covid 19 Data available live on the website [9].

The annual stillbirth rates are shown in Figure 3, and were 2.49, 2.85, 3.46, and 2.25 per 1,000 for the years 2018–2021. The rates for the first and second wave are compared in Table 3 and show stillbirth rates to be 54% higher in the first than the second wave p=0.08. The high rate during the first wave included a significant increase in SGA stillbirths (14 in 2020 vs. 2 in 2021; p=0.03). The causes of stillbirths are summarized in Table 4. The centile distribution of all stillbirths in the two years are shown in Figure 4.

Figure 3:

Annual stillbirth rates 2018–2021.

2021 covers period from January to September to coincide with 2nd wave.

Figure 4:

Stillbirth birthweight centile distribution.

Discussion

India struggled with the Covid pandemic, with the world’s highest number of Covid cases per day. The experience of Covid-19 pandemic was unique with healthcare services saturated with Covid cases, emphasis on emergency care on one side and the containment policies on the other side. Obstetric care has evolved over years and the morbidity, mortality rates decreased due to the emphasis on prevention of complications, planned antenatal care, appropriate timely screening for fetal and maternal deviations from normal. This planned antenatal care was disturbed by the first lockdown, fear of the disease, failure to go for routine antenatal care during the first lockdown, which is reflected by a fall in numbers of first visit registrations and total clinic numbers. The maximum drop was 71% coinciding with the month of April 2020, the month of lockdown and not the first and second waves of pandemic. The monthly average number of births in comparison did not decrease, but the lockdown reduced the numbers as seen in Figure 3. This was mostly due to restrictions in travel, closure of state borders and fear of infection. The parameters chosen to represent the reduction in access to planned antenatal care were those captured in electronic database and maintained.

There are many reports of reduction in antenatal care and an increase in stillbirths in Covid pandemic [1,2,10], [11], [12], [13]. The stillbirth rate in singleton pregnancies was chosen to represent a direct indicator of antenatal care, and more than 28 weeks was chosen in line with international definition [7]. The stillbirths around the lockdown in 2020 were very high reaching up to seven in a month against up to three in other months. The lockdown in the first wave did not coincide with the peak of the first wave of Covid pandemic. The lockdown was intense with complete restriction of movement, financial and economic crisis for many, leading to difficulty in access to non-emergency healthcare, including an absence of clinics and ultrasound services. The peak of the first and second wave of the Covid-19 pandemic did not coincide with an increase of stillbirths, reflecting the lockdown principles may have a role which needs to be studied.

The preventable stillbirths are those fetuses who are small, showing signs of growth lag in utero. Increased detection of SGA babies in antenatal care is known to decrease stillbirth rates [14]. Risk categorization, regular, planned serial assessment of symphysio-fundal height in low risk, serial fetal growth by ultrasound in high risk, has been shown to increase SGA detection rates before birth [14]. The disruption in antenatal care led to gaps in this pathway. The SGA proportion of total stillbirths was 14/32 (43.8%) in the first wave when compared to 2/14 (14.3%) in the second wave, more than double in proportion. The lessons learned from the first lockdown were applied to the second wave lockdown, and all healthcare facilities were kept open. The stillbirth rate in year 2018 was 2.49 and that in 2021 was 2.25 per 1,000. The impact of interruption of healthcare was very significant in year 2020 and antenatal care had to be redesigned. Team discussions were held to show SGA stillbirths have increased in year 2020 with audit of SGA detection rates and missed cases as a learning tool. The second wave of Covid-19 was unprecedented with massive numbers, traumatizing every home emotionally, economically, and financially. Even though the hospitals were completely overwhelmed with Covid cases, the stillbirth rate did not rise. The Covid-19 positive women in the hospital were only those who were symptomatic and tested by Covid-19 RT PCR. The Covid-19 positive numbers mentioned were small, and no stillbirth was seen in these women in our institute.

The world has seen pandemic containment and control policies in different countries. Lockdown of varying restrictions, durations can have an impact on non-emergency healthcare [10], [11], [12], [13]. We present our institutional stillbirth data with the antenatal care trends over the first and second waves with different lockdown policies. The limitations are small numbers, institutional data, and a small number of stillbirths. This is the first study comparing stillbirth rates in the first and second wave of pandemic in an institution that was using the GAP protocol for reduction of stillbirths for the past six years. An unprecedented crisis, we do not know the optimal method of containment of this pandemic or the effects on the health indicators. This data analysis and dissemination will help us to plan better, to avoid factors which had a negative impact, and facilitate those that promote better care.

Conclusions

The reduction in access to antenatal care due to lockdown was associated with a trend in increased stillbirths, with a significantly higher rate of potentially preventable SGA stillbirths. The increased incidence of stillbirths did not have a correlation to the peaks of Covid pandemic in terms of daily infection cases. The second wave was much more severe in comparison to the first wave, but there was no increase in stillbirths as the lockdown was much more planned and allowed all healthcare activities to continue.