Increase of stillbirth and decrease of late preterm infants during the COVID-19 pandemic lockdown

Mario De Curtis; Leonardo Villani; Arianna Polo

doi:10.1136/archdischild-2020-320682

Responses

PDF

XML

PostScript

Letter

Increase of stillbirth and decrease of late preterm infants during the COVID-19 pandemic lockdown

Compose a Response to This Article

Compose Response

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

PLEASE NOTE:

A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.

I agree to and have read the terms and conditions for rapid responses and BMJ Privacy Notice *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

Increase of stillbirth and decrease of late preterm infants during the COVID-19 pandemic lockdown
Mario De Curtis
Published on: 26 January 2021
First wave SARS-CoV-2 pandemic did not affect stillbirth prevalence.
Fabio Facchinetti, Enrica Perrone, Valeria Donno and Giovanni Grandi
Published on: 14 November 2020
Stillbirth rates should be carefully assessed, and women should not be blamed for adverse perinatal outcomes
Claudia Ravaldi, Alfredo Vannacci
Published on: 11 November 2020

Published on: 26 January 2021
Increase of stillbirth and decrease of late preterm infants during the COVID-19 pandemic lockdown
- Mario De Curtis, Professor of Paediatrics University of Rome, La Sapienza
Ravaldi et al. in their letter raise two points of dispute. The first is linked to epidemiological data and the other to the fact that, according to them, a reduction in gynecological checks during pregnancy did not occur in the lockdown of spring 2020. I appreciate their engagement with the article but I disagree.

On the first point (epidemiological data), the difference between the data presented by Ravaldi and those indicated by us is linked to the fact that they mistakenly refer to older years. Ravaldi’s 2019 stillbirth is taken from the Italian Statistical Yearbook 2019, which refers to the entire 2016. Our data, obtained from the CEDAP (hospital discharge database, which records perinatal information on all newborns), are instead those of Mar-May 2019 and Mar-May 2020 (3 months of lockdown).
Furthermore, Ravaldi’s stillbirth data starting from 22 weeks were taken from the ISTAT Reproductive Health document published in 2018, which refers to 2015 data. The authors therefore cannot contest the difference in the results because they are using different data sources. A further analysis (to be published) on larger samples on all births in Lazio confirmed a significant difference between stillbirths in the period March-May 2020 compared to the same months in the years 2017-2019 (3.23 vs 1.83 per thousand, p value = 0.014) . The increase in stillbirths in the first half of 2020 was observed in numerous developed and developing countries as well as in Italy (1-...
Show More

Ravaldi et al. in their letter raise two points of dispute. The first is linked to epidemiological data and the other to the fact that, according to them, a reduction in gynecological checks during pregnancy did not occur in the lockdown of spring 2020. I appreciate their engagement with the article but I disagree.

On the first point (epidemiological data), the difference between the data presented by Ravaldi and those indicated by us is linked to the fact that they mistakenly refer to older years. Ravaldi’s 2019 stillbirth is taken from the Italian Statistical Yearbook 2019, which refers to the entire 2016. Our data, obtained from the CEDAP (hospital discharge database, which records perinatal information on all newborns), are instead those of Mar-May 2019 and Mar-May 2020 (3 months of lockdown).
Furthermore, Ravaldi’s stillbirth data starting from 22 weeks were taken from the ISTAT Reproductive Health document published in 2018, which refers to 2015 data. The authors therefore cannot contest the difference in the results because they are using different data sources. A further analysis (to be published) on larger samples on all births in Lazio confirmed a significant difference between stillbirths in the period March-May 2020 compared to the same months in the years 2017-2019 (3.23 vs 1.83 per thousand, p value = 0.014) . The increase in stillbirths in the first half of 2020 was observed in numerous developed and developing countries as well as in Italy (1-5).

On the second point, we had not indicated the precise causes of the increase in stillbirths as we did not have the data, but the most probable cause is the postponement of many medical checks that have affected all ages of life. It is true that all mothers love their children, but undoubtedly there has been a reduction in compulsory pediatric vaccinations and a postponement of many checks for fear of contracting coronavirus infection by going to hospitals and medical centers. For example, there was a reduction in emergency room activities and consequent delay in the diagnosis of various diseases, including serious ones (6-8). In the published article we never intended to blame women but we limited ourselves to observing a phenomenon.
In addition, in the study from Ravaldi et. al (9-10), the authors use a very limited sample and as they are aware there is also the risk of a sample selection bias: “Women likely to respond may have been better connected to health care and may have better access to internet and electronic facilities”.

Mario De Curtis, Leonardo Villani, Arianna Polo

References

1.Dell'Utri C, Manzoni E, Cipriani S et al. Effects of SARS Cov-2 epidemic on the obstetrical and gynecological emergency service accesses. What happened and what shall we expect now? Eur J Obstet Gynecol Reprod Biol .2020 Nov;254:64-68 July 10, 2020

2.A Khalil, von Dadelszen P, Draycott Tet al. Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic

3.Watson C. Stillbirth rate rises during coronavirus pandemic. Nature 2020, 585: 490

4.Mor M, Kugler N, Jauniaux E et al. Impact of the Covid-19 pandemic on excess perinatal mortality and morbidity in Israel. Am J Perinatol.2020 Dec 10, doi: 10.1055/s-0040-1721515

5. Kumari V, Mehta K, Choudhary R. Covid-19 outbreak and decreased hospitalisation of pregnant women in labour Lancet Glob Health 2020 Sep; 8(9): e1116-e1117. doi: 10.1016/S2214-109X(20)30319-3

6. Ciacchini B, Tonioli F, Marciano C et al., Reluctance to seek pediatric care during the COVID-19 pandemic and the risks of delayed diagnosis, in J. Pediatr., 2020 Jun, 29; 46(1):87, doi: 10.1186/s13052-020-00849-w;

7. Dopfer C, Wetzke M, Zychlinsky Scharff A et al., COVID-19 related reduction in pediatric emergency healthcare utilization – a concerning trend, in BMC Pediatr., 2020 Sep 7; 20(1):427, doi:10.1186/s12887-020-02303-6;

8. Lynn R. M, L Avis JL, Lenton S et al., Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland, in BMJ Arch. Dis. Child., 2020 Jun 25, doi: 10.1136/archdischild-2020-319848.

9. Ravaldi C, Vannacci A, The COVID-ASSESS dataset - COVID19 related anxiety and stress in prEgnancy, poSt-partum and breaStfeeding during lockdown in Italy. Data in Brief 2020 33, 106440 https://doi.org/10.1016/j.dib.2020.106440

10. Ravaldi C, Wilson A, Ricca V, Homer C, Vannacci A, Pregnant women voice their concerns and birth expectations during the COVID-19 pandemic in Italy, Women Birth (2020), doi: 10.1016/j.wombi.2020.07.002
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 14 November 2020
First wave SARS-CoV-2 pandemic did not affect stillbirth prevalence.
- Fabio Facchinetti, Obstetric and Gynecology Mother-Infant Department, University of Modena and Reggio Emilia, Modena, Italy
- Other Contributors:
  Enrica Perrone, epidemiologist
  
  Valeria Donno, Resident in Obstetrics and Gynecology
  
  Giovanni Grandi, Obstetrics and Gynecologist
De Curtis et al reported some changes occurring in perinatal outcomes during lockdown in Lazio region, Italy. In particular, according to their data, preterm deliveries were reduced while stillbirth (SB) rate seems to be three-fold increased respect with the same period of 2019 (1).
We collected the same outcomes in Emilia-Romagna (ER), a northern Italian region with 4.47 million residents. Gestational age at delivery has been obtained by Birth Certificates (CedAP) while SB occurrence was collected from the Surveillance system of SB. This system is active since 2014. It records and audits, in a multidisciplinary way, each single case reported by every birth center of the Region. SB was defined according to WHO as published elsewhere together with other details of the Audit process (2).
In Emilia-Romagna, in the quarter March to May 2020, the one of the national lockdown, there were 22 SB (≥22+0 weeks) out of 6800 singletons births, for a rate of 3.24/1000. For the same quarter, in the previous 6 years, SB rate ranged from 2.86 (22/7687) in 2016 to 4.32 (31/7170) in 2019. According to one-way analysis of variance for 2014-2020 years, SB rate not changed significantly (p value >0.05 for each years of observation).
It has to be highlighted that a small number of events allow to a great variations in the rates, in a phenomenon such as SB that has a very low prevalence. For this reason, a comparison of only two points as previously done (1) could lead artif...
Show More

De Curtis et al reported some changes occurring in perinatal outcomes during lockdown in Lazio region, Italy. In particular, according to their data, preterm deliveries were reduced while stillbirth (SB) rate seems to be three-fold increased respect with the same period of 2019 (1).
We collected the same outcomes in Emilia-Romagna (ER), a northern Italian region with 4.47 million residents. Gestational age at delivery has been obtained by Birth Certificates (CedAP) while SB occurrence was collected from the Surveillance system of SB. This system is active since 2014. It records and audits, in a multidisciplinary way, each single case reported by every birth center of the Region. SB was defined according to WHO as published elsewhere together with other details of the Audit process (2).
In Emilia-Romagna, in the quarter March to May 2020, the one of the national lockdown, there were 22 SB (≥22+0 weeks) out of 6800 singletons births, for a rate of 3.24/1000. For the same quarter, in the previous 6 years, SB rate ranged from 2.86 (22/7687) in 2016 to 4.32 (31/7170) in 2019. According to one-way analysis of variance for 2014-2020 years, SB rate not changed significantly (p value >0.05 for each years of observation).
It has to be highlighted that a small number of events allow to a great variations in the rates, in a phenomenon such as SB that has a very low prevalence. For this reason, a comparison of only two points as previously done (1) could lead artifacts.
Moreover, another source of variation is represented by the Italian law which still defines any product of conception prior to 180 days of development (25 weeks and 5 days) as a miscarriage. We already reported that this underestimate SB rate when data collection is performed by using official statistical flow respect with a prospective recording in an active surveillance program (2).
Furthermore, the proportion of very premature births (<31+6 week) and moderate/late premature births (32+0-36+6) was not significantly different between the 2020 national lockdown period and the same calendar period from the previous 6 years (OR 0.88 – CI95% 0.67-1,16 and OR 0.91; CI 95% 0.80-1.03, respectively).

To understand differences with Lazio, it cannot be excluded that in 2020 there was an information bias (3) which led to a greater accuracy in the collection data and greater precision in the case definition in the pandemic than in the previous period. This hypothesis is supported by the very low rate of SB in 2019, much lower than reported in every European region.
Thus, we conclude from our findings that no changes occurred in SB during pandemic despite the rate of first Covid 19 spread in ER was 6.2/1000, almost five times higher than the one reported in Lazio (1.3/1000) (4).
During lockdown several emergency room accesses were significantly lesser requested by patients, including gynecological referrals (5). However, obstetric clinics of the National Health System did not change their offer and Obstetrics units never interrupted their perinatal cares.

In conclusion, statistical artifact or information bias could best explain the observed transitory increase of SB in Lazio rather a direct effect of infection or a supposed reduced utilization of NHS. We hope the findings here reported will be useful for larger data collection (entire set of data is available upon request) since only big databases could reliably conclude about perinatal outcomes.

References

1. De Curtis M, Villani L, Polo A. Increase of stillbirth and decrease of late preterm infants during the COVID-19 pandemic lockdown. Arch Dis Child Fetal Neonatal Ed. 2020 Oct 30:fetalneonatal-2020-320682. doi: 10.1136/archdischild-2020-320682. Epub ahead of print. PMID: 33127736.
2. Po' G, Monari F, Zanni F, Grandi G, Lupi C, Facchinetti F; Stillbirth Emilia-Romagna Audit Group. A regional audit system for stillbirth: a way to better understand the phenomenon. BMC Pregnancy Childbirth. 2019 Aug 5;19 (1):276. doi: 10.1186/s12884-019-2432-2. PMID: 31382995; PMCID: PMC6683556.
3. Kesmodel US. Information bias in epidemiological studies with a special focus on obstetrics and gynecology. Acta Obstet Gynecol Scand. 2018 Apr;97(4):417-423
4. Dipartimento della Protezione civile – Presidenza del Consiglio dei Ministri, accessed 13 Nov 2020. < http://www.protezionecivile.gov.it>
5. Grandi G, Del Savio MC, Caroli M, Capobianco G, Dessole F, Tupponi G, Petrillo M, Succu C, Paoletti AM, Facchinetti F. The impact of COVID-19 lockdown on admission to gynecological emergency departments: Results from a multicenter Italian study. Int J Gynaecol Obstet. 2020 Jun 30. doi: 10.1002/ijgo.13289. Epub ahead of print. PMID: 32602939.
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 11 November 2020
Stillbirth rates should be carefully assessed, and women should not be blamed for adverse perinatal outcomes
- Claudia Ravaldi, Psychiatrist CiaoLapo Foundation for Perinatal Health and Stillbirth support, Prato, Italy
- Other Contributors:
  Alfredo Vannacci, Professor of Pharmacoepidemiology
Stillbirths are tragic events with devastating consequences on women and couples: all efforts to better understand, manage and prevent their occurrence are welcome. Nevertheless, we have some concerns on what reported by De Curtis et al, who suggested an increase of stillbirth rate during the COVID-19 pandemic lockdown in Lazio, Italy.
1. First, we do not believe that a crude comparison with the corresponding months of 2019 is a proper control. Stillbirths are rare events, with a variable incidence during the year and alternating phases of low incidence and clusters of cases. The assumption that in the period Mar-May 2020 their number in the Lazio region should have been the same as of Mar-May 2019 is unsubstantiated. Consistently, the incidence reported by the authors in Lazio for 2020 (3.23 ‰) is almost the same of what reported for the same region in 2019 yearly statistics (3.00 ‰) [1] in which stillbirth is defined as a loss after 180 days (25 wks + 5 days). Furthermore, when using the 22 wks definition, reported stillbirth rate for Italy is significantly higher (4.70 ‰) [2].
2. Second, the authors suggest that the supposed increase could be due to reduced visits to hospitals due to the fear of contracting COVID-19. Unfortunately, this claim (that indeed blames women for the loss of their unborn child) is not at all supported by facts, as it wasn’t in the manuscript that the authors cite as a reference. Data from a sample of 2448 women who were pregnant or...
Show More

Stillbirths are tragic events with devastating consequences on women and couples: all efforts to better understand, manage and prevent their occurrence are welcome. Nevertheless, we have some concerns on what reported by De Curtis et al, who suggested an increase of stillbirth rate during the COVID-19 pandemic lockdown in Lazio, Italy.
1. First, we do not believe that a crude comparison with the corresponding months of 2019 is a proper control. Stillbirths are rare events, with a variable incidence during the year and alternating phases of low incidence and clusters of cases. The assumption that in the period Mar-May 2020 their number in the Lazio region should have been the same as of Mar-May 2019 is unsubstantiated. Consistently, the incidence reported by the authors in Lazio for 2020 (3.23 ‰) is almost the same of what reported for the same region in 2019 yearly statistics (3.00 ‰) [1] in which stillbirth is defined as a loss after 180 days (25 wks + 5 days). Furthermore, when using the 22 wks definition, reported stillbirth rate for Italy is significantly higher (4.70 ‰) [2].
2. Second, the authors suggest that the supposed increase could be due to reduced visits to hospitals due to the fear of contracting COVID-19. Unfortunately, this claim (that indeed blames women for the loss of their unborn child) is not at all supported by facts, as it wasn’t in the manuscript that the authors cite as a reference. Data from a sample of 2448 women who were pregnant or gave birth during COVID-19 lockdown in Italy [3] show indeed the opposite: concern for their own health was quite low in Italian mothers, while wellbeing of their child and care of their pregnancy were considered the most important tasks during lockdown [4].

1. ISTAT Annuario statistico italiano 2019 https://www.istat.it/it/files/2019/12/Asi-2019.pdf

2. ISTAT La salute riproduttiva della donna 2018 https://www.istat.it/it/files//2018/03/La-salute-riproduttiva-della-donn...

3. Ravaldi C, Vannacci A, The COVID-ASSESS dataset - COVID19 related anxiety and stress in prEgnancy, poSt-partum and breaStfeeding during lockdown in Italy. Data in Brief 2020 33, 106440 https://doi.org/10.1016/j.dib.2020.106440

4. Ravaldi C, Wilson A, Ricca V, Homer C, Vannacci A, Pregnant women voice their concerns and birth expectations during the COVID-19 pandemic in Italy, Women Birth (2020), doi: 10.1016/j.wombi.2020.07.002
Show Less

Conflict of Interest:
None declared.
- Back to top

Main menu

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Log in using your username and password

Main menu

Log in using your username and password

You are here

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Read the full text or download the PDF:

Log in using your username and password