Maternal outcome of pregnant and postpartum women admitted to intensive care unit due to COVID-19 infection: A retrospective study

Background: Previous data of COVID-19 indicates the obstetric population to be at specified risk for critical COVID-19 disease. In this study patient records were analyzed to gain information about the connection between pregnancy and intensive care treatment due to COVID-19 infection. Material(s) and Method(s): A retrospective study of all COVID-19 positive obstetric patients in Helsinki University Hospital admitted to intensive care units (ICU) from the beginning of March 2020 until the end of January 2022. Primary outcome is to compare the number of COVID-19 positive obstetric ICU patients to all ICU patients. Secondary outcomes are maternal 30-day survival and immediate neonatal survival. The study also looks at number of variables related to pregnancy and ICU treatment including age, previous medical history, BMI and COVID-19 vaccination status, obstetric data (i.e., gestational weeks, obstetric complications and route of delivery), treatments received at the ICU and length of ICU and hospital stay. Result(s): In total 20 obstetric patients with COVID-19 were admitted to the intensive care unit during the observation period. This is 2,3% of all COVID-19 patients and 27,4% of all 18-45 years old female COVID-19 patients treated in the intensive care unit in Helsinki University Hospital. Maternal 30-day survival was 95% (n = 19). Immediate neonatal survival was 95% (n = 19). Conclusion(s): Pregnancy increased the risk of ICU admission for COVID-19 infection. These results align with previous studies reporting pregnancy as a risk for critical COVID-19 infection and ICU admission. The 30-day survival was high compared to all ICU patients.

Successful Inter-Professional Team (IPT) collaboration in the care of peripartum women with COVID-19 on Extracorporeal Membrane Oxygenation (ECMO)

Objectives: To describe the IPT collaborative approach for peripartum women with COVID-19 on ECMO and report the intervention outcomes. Method(s): A retrospective electronic health record review was performed from January 2020 through January 2022. All peripartum women on ECMO with COVID19 admitted to the cardiothoracic intensive care unit (CTICU) were included. The IPT came together to coordinate peripartum care and delivery. An algorithm was created to outline the roles and workflow in the care of these patients. The outcomes evaluated included delivery method, timing, and location, maternal survival at discharge, maternal ICU length of stay (LOS), and neonatal survival Results: Thirteen Peropartum women were placed on ECMO (5 antepartum and 8 postpartum, ages 27-42). None had been vaccinated against COVID-19. All received femoral vessel cannulation (11 venovenous and 2 venoarterial). Four patients underwent Caesareansection delivery while on ECMO. Maternal survival to hospital discharge was 84.6%. All neonates survived with COVID-19 negative status. Conclusion(s): The collaborative IPT approach with a structured algorithm facilitated survival outcomes. This report adds to the limited literature on peripartum. ECMO and provides insights to consider in planning for the care of these patients.

Determination of COVID-19 Mortality and Morbidity in Women Who Had Cesarean Sections and Terminated Pregnancies

Background: COVID-19 infection is a contemporary global concern with serious ramifications. This disease is caused by a virus belonging to the Coronaviridae family named SARS-CoV-2. Immunologic and physiologic changes during pregnancy make pregnant women more susceptible to viral infection, especially COVID-19. Objective(s): The present study aimed to identify the clinical manifestations, radiologic findings, indications for cesarean delivery, underlying conditions, and the critical outcome of mothers and newborns regarding COVID-19 women who had cesarean sections and terminated pregnancies. Method(s): This cross-sectional study was conducted on the mortality and morbidity rates of 98 women with terminated pregnancies infected with COVID-19 at the time of their cesarean delivery. The demographic, clinical, and pregnancy data were collected from Razi Teaching Hospital between March 2020 and March 2021 and analyzed using SPSS version 24. Result(s): The mean age was 31.31 +/- 7.16, and the mean gestational age was 36.45 +/- 3.334 weeks. The most prevalent cause of cesarean section was fetal distress (28%), followed by preeclampsia and meconium aspiration. The most common symptoms were sore throat, cough, fever, nausea, diarrhea, and weakness;moreover, hypothyroidism and diabetes mellitus were the most predominant underlying diseases. The mean duration for hospitalization was 5.21 +/- 4.584 days, the maternal death rate was 5.1%, and the neonatal death rate was 2%. Conclusion(s): The majority of women infected with COVID-19 had cesarean sections and terminated pregnancies in the third trimester. This highlights the need for better care and education for mothers in this period. The body mass index (BMI) level and obesity are strongly associated with COVID-19 severity. Furthermore, healthcare workers should pay more attention to underlying diseases during pregnancy.Copyright © 2023, Author(s).

Ethical Lessons Learned from the COVID-19 Pandemic in Perinatal Medicine

The COVID-19 pandemic is unprecedented in our lifetime, especially in perinatology. The gold standard is to strongly recommend COVID-19 vaccinations to those trying to get pregnant, to those who are pregnant, and to those who are postpartum. When the benefits of vaccines far outweigh the risks, it is unethical to disseminate wrong information and discourage patients from becoming vaccinated. COVID-19 vaccinations and boosters prevent severe diseases and adverse pregnancy and neonatal outcomes. A pregnant patient's vaccination also protects the newborn infant because maternal antibodies protect the fetus and newborn. COVID-19 vaccinations and boosters in pregnancy are safe for the pregnant patient and her fetus. The three root causes of physician hesitancy-misapplication of therapeutic nihilism, misapplication of shared decision-making, and misapplication of respect for autonomy should not be ignored and need to be addressed. It is important that we heed Brent 's insightful recommendations. Doing nothing with respect to vaccination is not an option, whether it applies to COVID-19 vaccines or to future pandemics. Physician hesitation is not an option. When there is sufficient evidence of vaccine safety and effectiveness without documented risks, vaccine recommendations before, during, and after pregnancy should be explicitly made to prevent maternal, fetal, and neonatal morbidity and mortality.Copyright © The Author(s). 2023.

COVID-19 infection in pregnancy: A single-center experience in Rize in the Eastern Black Sea Region

Aim: In this study, it was aimed to share the clinical experiences of mothers and their babies (perinatal, natal) who encountered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy. Material(s) and Method(s): The study was carried out retrospectively, 62 pregnant individuals were diagnosed with the 2019 coronavirus disease (COVID-19). Demographic characteristics, clinical course, laboratory and radiological findings and clinical results of the baby were evaluated by examining electronic and file records. Result(s): The average age of the 62 pregnant women included in the study was 29.8+/-4.7 (19-42) years, and the average gestational week at the time of admission was 28.5+/-10.4 (5-40) weeks. More than half of the patients (80,6%) on admission were in their third trimester. The most common initial symptoms were cough (45.2%), myalgia (43.5%),) fever (21%). In total, 15 of the pregnant women had evidence of COVID-19 pneumonia in lung involvement. The PCR test results of all pregnant women were positive. There were three cases admitted to the intensive care unit, one of whom was due to gestational diabetes. No maternal mortality was recorded. One gestation ended in a miscarriage and two women gave birth prematurely. One stillbirth occurred at the 33h week of gestation. Among 22 neonates, two were admitted to the neonatal intensive care unit. Neonatal mortality, congenital malformation, and mother-to-child transmission were not observed in newborns. Discussion(s): The results of our study suggest that the clinical course of COVID-19 infection in pregnant women was mostly asymptomatic/mild.Copyright © 2022, Derman Medical Publishing. All rights reserved.

The impact of covid-19 on women's health in nepal

COVID-19 has significantly impacted the world and Nepal is no exception. The pandemic has caused a reduction in health service delivery, especially for women's health conditions, resulting in an increase in challenges for an already vulnerable group. Maternity care, reproductive health services, preventive interventions, nutritional advice and mental health care are not being addressed and with an increase in domestic violence, the health and wellbeing of women in Nepal is precarious and needs to be addressed immediately. Copyright © 2020, Kathmandu University. All rights reserved.

Multisectoral Factors Associated with Global National Trends in Neonatal Mortality Rates: A Call for Targeted Public Health Intervention, Particularly in Countries Impacted Most by COVID-19

Background: The United Nations' 2030 Sustainable Development Goals (SDGs) target an end to preventable newborn deaths and a reduction in neonatal mortality rate (< 28 d, NMR) to 12/1,000 live births for all countries. Understanding concurrent trends in country-level, multisectoral factors associated with NMR trends may illuminate opportunities for intervention strategies. Our objective was to explore country-specific trends in NMR from 1990-2019 and identify those countries which contribute to the largest percentage of neonatal deaths in order to focus efforts on reducing NMRs in those specific countries. Unfortunately, due to the COVID-19 pandemic, the 2030 SDGs have been severely impacted. Methods: We created a comprehensive global database of NMR and associated variables that were selected based on literature review and categorized into Population Health, Health Systems, Maternal, Neonatal, and Social factors from 1990 to 2019. Data were compiled from publicly available sources including UNICEF, World Bank, WHO, and OECD. Data were collected and analyzed for 195 countries. NMR trends were analyzed from 1990 to 2019 with more targeted analysis of trends in the last 2 decades from 2000 to 2019. We then performed statistical analyses using the selected variables to compare variable means using t-tests, identify bivariate associations, and generate multivariable regression models. Results: In terms of total deaths, 20 countries contributed 75% of the total 2.5 million neonatal deaths. All of these 20 countries showed decreases in NMR since 1990 (Figure 1). However, only China and Egypt accomplished the UN goal of reducing NMR to 12/1,000 live births. We compared variables associated with NMR in our 20 target countries to the remaining countries and found significant differences between the means for most variables (Table 1). Bivariate regression analyses showed statistically significant associations between NMR trends and changes over time in median income, health care spending, literacy level, maternal mortality ratio, and low birthweight rate. Ultimately the variables maternal mortality ratio change and median income change were selected for multivariable analysis based on collinearity. The multivariate regression model generated using NMR, maternal mortality ratio change, median income change resulted in an r-squared value of 0.54, explaining 54% of the variance in NMR trends. Conclusion: Since 20 countries contribute 75% of the neonatal deaths worldwide, we propose that targeting these 20 countries would have the greatest impact on global neonatal deaths. Future research will focus on identification of country specific barriers and evaluating the countries with greatest NMR improvements to propose effective focused strategies for reducing NMRs in high burden countries. The disparate impact that COVID-19 has had on countries with the highest neonatal mortality burden should be a primary focus of continued public health invention efforts, and is a specific focus of our ongoing research.

Mentoring Quality Improvement Teamsin Ethiopia via a Virtual Partnership Between the American Academy of Pediatrics and the Ethiopian Pediatric Society

Background: Despite a marked decline in worldwide under-five mortality over the past 30 years, the largest proportion of these deaths remain neonates. In 2018, 4 million (75% of all under-five deaths) infants died worldwide [1]. The neonatal mortality rate in Ethiopia was 28.1 per 100 live births, compared to 17.7 globally and 27.2 in Africa, ranking 23rd for highest neonatal mortality [2]. The Ethiopian Pediatric Society (EPS), entered a virtual partnership with the American Academy of Pediatrics (AAP) in 2020 to provide educational and practical support to clinicians in Ethiopia to perform quality improvement (QI) research. QI training for clinicians at eight Ethiopian sites is modeled on Project ECHO (Extension for Community Healthcare Outcomes) [3]. ECHO improves capacity for specialists to deliver care to underserved communities via collaboration with local clinicians using video teleconferencing, which has been a particularly advantageous tool to continue global health work during the COVID-19 pandemic. The goal of this project is to support local Ethiopian providers in designing, implementing, and assessing a QI intervention. Methods: We adapt the Project ECHO model to have U.S. neonatology faculty-fellow teams mentor clinicians from 8 hospitals in Ethiopia. Using video conferencing and regular contact through mobile devices, teams work to identify gaps in care, create SMART aim statements, identify key stakeholders and barriers to change, and implement interventions. Interventions are measured with a phone application, Liveborn, which allows instant transmission of data internationally. Sites provide monthly progress updates to the EPS. AAP/EPS leadership, U.S.-based faculty-fellow teams, and QI team leaders meet monthly via video conference for didactic sessions on QI methodology followed by teams presenting their progress, which promotes discussion and collaboration between the sites, AAP/EPS leadership, and U.S. mentorship teams to address any barriers. Results: Teams identified compliance with delayed cord clamping (DCC) and skin-to-skin (STS) after delivery as a gap by independently collecting local data. QI teams are currently still implementing interventions and measuring improvement. Teams have identified several barriers, the most common cited being stakeholder buy-in and logistic challenges in implementation. During monthly meetings, teams continually discuss and brainstorm ways to address barriers overall and among individual sites. Conclusion: Via the ECHO model, the AAP and EPS are supporting Ethiopian QI teams in designing and implementing QI interventions despite the limitations imposed by the COVID-19 pandemic. Challenges to this mentorship process include communication barriers (language, internet network) and perception of lack of need by Ethiopian clinicians for U.S. mentorship. Using the ECHO model, all teams have defined SMART aims, begun to implement interventions, and are now collecting compliance data.

Assessment of newborn health dynamics after the Russian Federation transition to international criteria for live births and stillbirths

To assess the state of children’s health in obstetric care organizations after Russia transition to international statistics on live births and stillbirths, we studied the main indicators of newborn health in the dynamics from 2013 to 2020. It was found that between 2013 and 2020 the morbidity of newborns decreased by 6.3% (from 337.2‰ to 316.3‰;p<0.05), neonatal mortality by 45.7% (from 3.5‰ to 1.9‰;p<0.05), stillbirth rate by 45.6% (from 10.9‰ to 5.5‰;p<0.05), and hospital mortality of newborns born sick and ill by 40.0% (from 1.0% to 0.6%;p<0.05). Assessment of the distribution of live-born infants by birth weight showed that changes in this parameter of physical development during the period under study had no statistically significant differences (p>0.05). The assessment of the impact of the COVID-19 pandemic on newborn health revealed slight shifts in the distribution of children born alive by birth weight and a 6.8% increase in the stillbirth rate compared to the pre-pandemic level. Thus, in the period from 2013 to 2020 the share of children discharged from obstetric hospitals who were healthy has increased due to the reduction in morbidity and mortality of newborns. The analysis showed that there was an improvement in the health indicators of newborns in the Russian Federation.

Comparison of Characteristics and Outcomes of Pregnant Women with COVID-19 in First and Second Wave Admitted in a COVID Hospital in Arunachal Pradesh: A Retrospective Observational Study

Introduction: Coronavirus Disease-2019 (COVID-19) has affected the pregnant women and newborn child across the world. Empirical data shows that the characteristic of the effect of COVID-19 virus varies between the subsequent wave. Aim: To compare the demographic characteristics, severity of illness, Intensive Care Unit (ICU) admissions, maternal and neonatal outcomes in COVID-19 positive pregnant women of first and second wave. Materials and Methods: A retrospective observational study was conducted at dedicated COVID-19 Hospital under Tomo Riba Institute of Health and Medical Sciences (TRIHMS) in Itanagar, Arunachal Pradesh, India. All COVID-19 positive pregnant women admitted between July 2020 and August 2021 were included in the study. The patients admitted during 1st July 2020 to 31st January 2021 were considered in 1st wave of COVID-19 and those from 1st February 2021 to 31st August 2021 as 2nd wave of COVID-19. Data of baseline characteristics, clinical presentations, severity, ICU admissions, abortion, modes of delivery, Neonatal Intensive Care Unit (NICU) admission, maternal and neonatal mortality were analysed and compared. Results: A total of 144 COVID-19 positive pregnant women admitted from July 2020 to August 2021 were included in the study. Of 144 patients, 58 were in first wave and 86 in second wave of COVID-19. Number of moderate and severe cases admitted was 23.3% and 7% during second wave compared to only 12.1% moderate case only in first wave (p-value=0.015). Three pregnant women died due to severe COVID-19 pneumonia during the second wave. NICU admissions and other neonatal outcomes were comparable in both the study groups. Conclusion: A significantly increase number of pregnant women were affected with severe COVID-19 morbidity and mortality in second wave. Neonatal outcomes were similar in both waves.

COMPARATIVE ANALYSIS OF STILLBIRTH CAUSES AND RATES IN THE RUSSIAN FEDERATION IN 2019 AND 2020

Aim: To make a comparative analysis of causes and rates of early neonatal mortality in the Russian Federation in 2019 and 2020. Materials and methods: This study was based on the analysis of statistical forms А-05 of the Federal State Statistics Service (Rosstat) for the years 2019–2020. These forms included medical records of perinatal deaths related to stillbirths. Stillbirth rates were calculated as the ratio of stillbirths to the total number of babies born alive and dead multiplied by 1000. Results: In 2020, the number of babies born alive decreased by 7.6%, and the number of babies born dead increased by 1.12% versus the data reported in 2019. In 2020, the rate of stillbirth (5.67‰) increased by 4.2% versus the rate in 2019 (5.44‰). Most of all, the increase in stillbirths was noted in the South and Siberian Federal Districts. In general, the most common causes of stillbirths in the Russian Federation were respiratory disorders: the number of antenatal hypoxia was 78.2 (80.5%) and fetal intrapartum hypoxia was 6.7 (5.0%) of total number of stillbirths in 2019 and 2020, respectively. The proportion of congenital anomalies as the main disease was 6.7 (5.4%) of total number of stillbirths in 2019 and 2020, respectively. It was noted, that the number of stillborn babies with unknown causes of death increased by 52.2% in 2020 (4.7% of total number of stillborn babies) versus 2019 (3.1% of total number of stillborn babies)). Significant differences between the rates of major diseases that caused stillbirths were registered in different Federal Districts of the Russian Federation. Conclusion: According to Rosstat data, in 2020 (due to COVID-19 pandemic), the absolute number of babies born dead increased by 1.1% and the rate of stillbirths increased by 4.2% compared to 2019. Increased proportion of respiratory diseases, in particular, antenatal hypoxia and congenital pneumonia, reflects the direct and indirect effects of SARS-CoV-2 infection.

SARS-CoV-2 INFECTION and PREGNANCY in AFRICA: A 6-COUNTRY RETROSPECTIVE COHORT STUDY

Background: Limited data are available on pregnancy and COVID-19 in sub-Saharan Africa (SSA). Methods: We conducted a retrospective cohort study of women ≥18 years old hospitalized at 23 health facilities in six SSA countries between March 1, 2020, and March 31, 2021. We assessed the impact of pregnancy on SARS-CoV-2 infection, and of SARS-CoV-2 on pregnant women, through comparisons of clinical outcomes among: 1) pregnant and non-pregnant women hospitalized with RT-PCR-confirmed SARS-CoV-2 infection, and 2) pregnant women confirmed to be positive or negative for SARS-CoV-2 infection by RT-PCR. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included need for oxygen supplementation or mechanical ventilation, pregnancy outcomes, and maternal or neonatal mortality. We performed negative log-binomial regression models to estimate the impact of pregnancy on SARS-CoV-2 among all women in the cohort, and the impact of SARS-CoV-2 on pregnancy outcomes. Factors associated with mortality were evaluated using competing-risk regression based on Fine and Gray's proportional hazards model. Results: We analyzed data on 1,315 hospitalized women: 510 pregnant women with SARS-CoV-2 infection;403 non-pregnant women with SARS-CoV-2 infection, and 402 pregnant women without SARS-CoV-2 infection. Among those with SARS-CoV-2 infection, pregnancy was associated with increased risk of ICU admission (adjusted rate ratio [aRR]= 1.86, 95% CI: 1.07-3.22, p=0.003) and oxygen supplementation (aRR= 1.48, 95% CI: 1.06-2.08, p=0.001). Among pregnant women, those with SARS-CoV-2 infection had increased risk of ICU admission (aRR = 2.0, 95% CI: 1.20-3.35, p=0.008), oxygen supplementation (aRR = 1.57, 95% CI: 1.17-2.11, p=0.002) and maternal mortality (aRR=3.08, 95% CI: 1.21-7.85, p=0.018) (Figure). Comparing SARS-CoV-2-infected vs. uninfected pregnant women, infected women were more likely to deliver by Caesarean section (59.3% vs 37.9%, RR = 1.56, 95% CI: 1.29-1.89, p<0.001);however, proportions of pre-term infants (32.4% vs. 31.1%, respectively, p = 0.870), infants with low birth weight (33.8% vs. 30.9%, respectively, p=0.711) and neonatal deaths [8/209 (3.8%) vs. 8/306 (2.6%) (RR=1.46, 95% CI: 0.56-3.84, p=0.436, respectively)] were similar. Conclusion: Among hospitalized pregnant women, SARS-CoV-2 infection increased morbidity and mortality. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

THE IMPACT of COVID-19 on ADVERSE BIRTH OUTCOMES in BOTSWANA by HIV STATUS

Background: Botswana has a high prevalence of women living with HIV (WLHIV) and experienced a severe nationwide COVID-19 epidemic in 2021. We evaluated adverse birth outcomes among women routinely tested for COVID-19 by HIV status, during a period when few women had access to COVID-19 vaccination. Methods: The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. We analyzed data from 13 Tsepamo sites that performed routine COVID-19 screening at delivery with rapid antigen or PCR testing between Sept 1, 2020 and Sept 30, 2021 (start dates differed by site). This analysis includes singleton deliveries with known HIV status and a COVID-19 screening test between 14 days prior and 3 days after delivery. Outcomes included maternal death, preterm delivery (PTD), very preterm delivery (VPTD), small for gestational age (SGA), very small for gestational age (VSGA), stillbirth, and neonatal death. Differences in outcomes by COVID-19 and HIV status were assessed using log binomial regression adjusted for maternal age. Results: A total of 17,627 deliveries occurred at the included sites during COVID-19 screening, and 11,149 (63.3%) were screened for COVID-19;among 10,090 (99.7%) with a known HIV status, 530 (5.3%) COVID-19 tests were positive, including 141/2129 (6.6%) among WLHIV and 389/7961 (4.9%) among women without HIV (aRR 1.32, 95% CI 1.09, 1.60). Maternal deaths were reported in 19 (3.8%) women with COVID-19 and 11 (0.12%) women without COVID-19 (aRR 30.5, 95% CI 14.6, 63.7), and did not differ by HIV status. Adverse birth outcomes (any) were more common among infants born to women with COVID-19 (34.3% vs. 26.3%;aRR 1.32, 95% CI 1.16,1.49), including PTD (21.2% vs. 13.3%;aRR 1.60, 95% CI 1.34,1.90) and stillbirth (5.5% vs. 2.8%;aRR 1.89, 95% CI 1.30,2.75), and there was a trend for higher neonatal mortality (2.0% vs. 1.4%, aRR 1.5, 95% CI 0.79, 2.85). Most adverse birth outcomes were highest among infants exposed to both COVID-19 and HIV (Figure 1). Conclusion: Infants born to women with COVID-19 experienced more adverse birth outcomes than other infants, including a 2-fold risk for stillbirth. Those exposed to both COVID-19 and HIV had the highest risk for most adverse outcomes. Further research is warranted to understand the biological interaction between COVID-19, HIV infection, and adverse birth outcomes, and whether some associations were impacted by challenges in care delivery during the height of the COVID-19 epidemic in Botswana.

IS HBB ENOUGH? EXPERIENCES WITH QI ACTIVITIES FOR BIRTH ASPHYXIA IN AN LMIC HOSPITAL THROUGH GLOBAL VIRTUAL TEAMWORK

Purpose of Study Birth asphyxia is a major cause of neonatal mortality in low- and middle-income countries (LMIC). A Blended Learning Program was set up by Georgetown University (GU) faculty for quality improvement (QI) activities in several district hospitals in Ghana (funded by GU Global Health Initiative). Birth asphyxia was selected as the top priority by the Ghana staff, specially focusing on resuscitation at birth. The in- country workshop was cancelled due to the COVID pandemic. However, facilitation of QI activities was carried out using digital technology. We share the impact of this program in one Ghana regional hospital. Methods Used Hospital staff had received in-country training in AAP-Helping Babies Breathe (HBB) course earlier. Using Zoom and WhatsApp, the GU faculty worked with health care providers to facilitate QI activities to improve resuscitation at birth. This included setting up a QI team, correct documentation of Apgar scores, refresher courses, practices on a manikin, promoting having at least two persons at each birth and ensuring appropriate equipment being kept in readiness. Monthly changes in proportion of babies ≥ 34 wks. gestational age whose Apgar score rose from £ 6 at 1 min. to ≥ 7 at 5 min of age were monitored. Pre-and post-intervention periods were Oct-Dec 2019 and Jan 2020 to Mar 2021. The program was considered exempt from review by the GU IRB. Summary of Results Figure 1 indicates the proportion of babies in whom the Apgar score rose from £ 3 at 1 min to > 4 at 5 min and those in whom the score rose from 4-6 at 1 min to ≥ 7 at 5 min. No significant difference was noted between the pre and post intervention periods. Table 1 shows that among 112 newborns with a 1minute Apgar score of £ 3, the scores remained at £ 3 at 5 minutes in about 50% of babies despite resuscitation attempts until the 4th quarter;17 (37%) of these infants died. Table 2 shows that in 639 infants with Apgar scores of 4-6, the scores did not improve to > 7 in 75 babies (11.7%);there were 5 deaths (0.8%) attributed to birth asphyxia in this group. Conclusions The improvement in Apgar scores showed that HBB had a positive effect. However, to have the full desired impact on outcome in newborns with birth asphyxia, it is essential to go beyond 'HBB' to a more comprehensive 'Mother-Baby Approach' where management addresses prevention and treatment. This includes (a) Counseling in the antenatal period promoting mothers to reach the facility at the appropriate time in labor (b) 'Helping Mothers Deliver' through capacity building of the maternal health staff for competency in optimal management of labor and delivery (c) 'HBB' to improve competence related to neonatal resuscitation (d) Better communication and coordination between maternal and newborn health staff and (e) Post resuscitation care of the baby. (Table Presented).

FACILITATING QI ACTIVITIES GLOBALLY THROUGH DIGITAL TECHNOLOGY: DECREASING SEVERE NEONATAL HYPERBILIRUBINEMIA

Purpose of Study Severe Neonatal Hyperbilirubinemia (SNH) is a major cause of neonatal mortality in Sub-Saharan Africa and can cause neurodevelopmental disability in survivors. Exchange transfusions (ET) to reduce high bilirubin levels are common in low/middle income countries (LMIC) due to late detection of jaundice. Mothers are often discharged from hospital < 24 hours after delivery. A Blended Learning Quality Improvement (QI) Program using digital technology (the in- country workshop was cancelled due to COVID 19 pandemic) was developed between Georgetown University (GU) and district hospitals in Ghana to improve quality of neonatal care (funded by GU Global Health Initiative). The objective of this program was to facilitate QI activity at a Ghana District Hospital (GDH) promoting early care seeking in mothers for neonatal jaundice so that phototherapy may be used to decrease SNH and ET. Methods Used GU faculty used Zoom and WhatsApp platforms to work with GDH staff to facilitate formation of a QI team, implement interactive health education with videos by trained midwives for antenatal/post-partum mothers, initiate daily rounds by physicians in postnatal wards, promote community health nurses to call/visit mothers postnatally at home, and maintain data on pre-defined key outcome indicators. The goal was to reduce the proportion of inborn infants ≥ 34 weeks gestational age being brought to the neonatal unit with SNH (serum bilirubin levels ≥ 340umol/L or 20 mg/dL) by 15% within 3 months. The program was exempted from review by the GU IRB. Statistical analysis: Chi- square;Fisher exact test. Summary of Results From Oct 2019 to Jan 2020, 14 (28%) of 50 discharged infants were readmitted with SNH and 7 (14%) received ET. Figure 1 shows the trend graph of infants admitted with SNH and ET each month after the initiation of the QI project in Jan 2020. Table 1 shows the decline in SNH and ET in the 3 months post intervention as well as a significant sustained decline for 16 months. There was a significant increase in infants being brought in for bilirubin levels < 255umol/L after the intervention. Conclusions Despite internet connectivity problems, this digitally mediated QI project demonstrated success in reduction of SNH and ET in a district hospital in a LMIC. Regular review of trend graphs and repeated facilitation, implemented through low-cost digital technology, are effective in promoting QI activities and can be applied regionally and globally. The increase in infants being brought in for mild jaundice points to the need for objective methods of determining bilirubin levels in the community. (Figure Presented).

Association between the COVID-19 pandemic and fetal, neonatal, and maternal outcomes: An Alabama population-based study

Purpose of Study It is important to identify possible changes in fetal, neonatal, and maternal outcomes in relation to the beginning of the COVID-19 pandemic using population-based data to inform strategies to mitigate the impact of the pandemic on adverse pregnancy outcomes. Objective To test the hypothesis that the COVID-19 pandemic was associated with a higher rate of stillbirth and a lower rate of neonatal mortality. Methods Used Design: This population-based cohort study compares two epochs: calendar weeks 9-52 (defined as week one starting on the first Sunday of the year) of the years 2016 to 2019 (baseline period)) and 2020 (pandemic period). Setting: Data from the Alabama Department of Public Health, Center for Health Statistics database of Alabama state residents who delivered in Alabama. Participants: All pregnant women with stillbirths ≥20 weeks and live births ≥22 weeks gestational age. Primary Outcomes: The stillbirth and neonatal mortality rate. Summary of Results Data on 237,625 pregnant women were included;46,816 were from the pandemic and 190,809 were from the baseline period. On bivariate analysis, the stillbirth rate did not differ (8.1 vs. 8.9/1000 births, p-value=0.104), but the neonatal mortality rate was lower (2.8 vs. 4.5/1000 live births, p-value<0.001), and the maternal mortality rate was higher (102.5 vs. 62.4/100,000 births, p-value=0.003) during the COVID-19 pandemic period as compared to the baseline period. On logistic regression analysis adjusting for socio-demographic variables (maternal race, age, education, and prenatal care), the pandemic period was associated with a decrease in stillbirth (OR=0.76, 95%CI=0.64, 0.91, pvalue= 0.002) and neonatal mortality rate (OR=0.62, 95% CI=0.51-0.75, p-value<0.001) but an increase in maternal mortality rate (OR=1.64, 95% CI=1.17-2.30, P-value=0.003) as compared to the baseline period. Conclusions The current population-based study shows that the COVID-19 pandemic period was associated with no change in the stillbirth rate, a lower neonatal mortality rate, and a higher maternal mortality rate compared to the baseline period.