Impact of COVID-19 Lockdowns on Rates of Adolescent Pregnancies: A Systematic Review (preprint)

Background: Education is known to protect adolescent girls from unplanned pregnancy. School closures were component of COVID-19 “lockdown measures”. The impact of these measures on adolescent pregnancy worldwideis unknown.  Methods: We performed a systematic review to find evidence of the impact of “lockdowns” and school closures on adolescent pregnancy events during the COVID-19 pandemic. Databases including Pubmed, EMBASE, CINAHL, WHO Index Medicus, and Literatura Latinoamericana y Caribe en Ciencias de la Salud (LILACS) were searched. Studies that provided data on pregnancy rates in girls aged 10-19 before, during, and after the onset of the COVID-19 pandemic (defined as March 2020) were eligible for inclusion. Extracted data included study design, study location, age of participants, exposure period, and percentage or pregnancy rate data. Findings: On August 21st, 2023, 3049 studies were screened, with 79 eligible for full-text review. Ten studies were included in the final review: Seven performed in Africa (Uganda, Kenya, South Africa, and Ethiopia), and three in the Americas (USA and Brazil). Adolescent pregnancy increased in six out of the seven African studies while a decrease or no change was noted in USA and Brazil.All studies were at a high risk of bias. Interpretation:   Adolescent pregnancy rates during the COVID-19 pandemic may have substantially increased in sub-Saharan Africa. Data scarcity and low-quality evidence are significant limitations. The dynamic relationship between lockdown measures and adolescent pregnancies warrants ongoing multifaceted research and adaptive policies to safeguard adolescent sexual and reproductive health during health crisis. Systematic Review Registration: PROSPERO registration number CRD42022308354.

Seroepidemiology of COVID-19 in pregnant women and their infants in Uganda and Malawi across multiple waves 2020-2022 (preprint)

Background: Data on SARS-CoV-2 infection in pregnancy and infancy has accumulated throughout the course of the pandemic. However, limited information is available from countries in sub-Saharan Africa (SSA). Evidence regarding asymptomatic SARS-CoV-2 infection and adverse birth outcomes are also scarce in these countries. The pregnant woman and infant COVID in Africa study (PeriCOVID Africa) is a South-South-North partnership involving hospitals and health centres in five countries: Malawi, Uganda, Mozambique, The Gambia, and Kenya. The study leveraged data from three ongoing prospective cohort studies: Preparing for Group B Streptococcal Vaccines (GBS PREPARE), SARS-CoV-2 infection and COVID-19 in women and their infants in Kampala and Mukono (COMAC) and Pregnancy Care Integrating Translational Science Everywhere (PRECISE). In this paper we describe the seroepidemiology of SARS-CoV-2 infection in pregnant women enrolled in sites in Uganda and Malawi, and the impact of SARS-CoV-2 infection on pregnancy and infant outcomes. Methods: The PeriCOVID study is a prospective mother-infant cohort study that recruited pregnant women at any gestation antenatally or on the day of delivery. A nasopharyngeal swab was taken from mothers at enrolment for RT-PCR confirmation of SARS-CoV-2 infection, and maternal and cord blood samples were tested for SARS-CoV-2 antibodies using Wantai and Euroimmune ELISA. The primary outcome was seroprevalence of SARS-CoV-2 antibodies in maternal blood, reported as the proportion of seropositive women by study site and wave of COVID-19 within each country. Placental transfer of antibodies was described using the geometric mean ratio (GMR). We also estimated the proportion of asymptomatic or subclinical COVID-19 infections in pregnant women using serological testing, and collected adverse pregnancy and infancy outcomes (e.g. still-birth, prematurity, maternal or infant death). Results: In total, 1379 women were enrolled, giving birth to 1387 infants. Overall, 63% of pregnant women had a SARS-CoV-2 positive serology. Over subsequent waves (delta and omicron) , in the absence of vaccination, seropositivity rose from 20% to over 80%. The placental transfer GMR was 1.7, indicating active placental transfer of anti-spike IgG. There was no association between SARS-CoV-2 antibody positivity and adverse pregnancy or infancy outcomes. Discussion: This study describes the increasing prevalence of SARS CoV-2 antibodies in pregnant woman in Uganda and Malawi across waves of SARS-CoV-2 infection. Our study adds to existing evidence that suggests under-reporting of infection if based solely on cases with clinical disease, or a positive RT-PCR for SARS-CoV-2, as most of the women in our study had asymptomatic infections and did not seek medical care. This has implications for screening in subsequent outbreaks and pandemics where protection of pregnant women and effect of infection in pregnancy on the infant are unknown.

Neonatal outcomes and indirect consequences following maternal SARS-CoV-2 infection in pregnancy: A systematic review (preprint)

Objectives Identify the association between maternal SARS-CoV-2 infection in pregnancy and individual neonatal morbidities and outcomes, particularly longer-term outcomes such as neurodevelopment. Setting Case-control and cohort studies from any location published after 1st January 2020, including pre-print articles. Participants Neonates born to pregnant women diagnosed with a SARS-CoV-2 infection at any stage during pregnancy, including asymptomatic women. Primary and secondary outcome measures Neonatal mortality and morbidity, including preterm birth, Caesarean delivery, small for gestational age, admission to neonatal intensive care unit, level of respiratory support required, diagnosis of culture-positive sepsis, evidence of brain injury, necrotising enterocolitis, visual or hearing impairment, neurodevelopmental outcomes, and feeding method. These outcomes were selected according to a Core Outcome Set developed between health professionals, researchers and parents. Results The search returned 3234 papers, from which 204 were included with a total of 45,646 infants born to mothers with SARS-CoV-2 infection during pregnancy across 36 countries. We found limited evidence of an increased risk of some neonatal morbidities, including respiratory disease. There was minimal evidence from low-income settings (1 study) and for neonatal outcomes following first trimester infection (17 studies). Neonatal mortality was very rare. Preterm birth, neonatal unit admission and small for gestational age status were more common in infants born following maternal SARS-CoV-2 infection in pregnancy in most larger studies. Conclusions There is limited data on neonatal morbidity and mortality following maternal SARS-CoV-2 infection in pregnancy, particularly from low-income countries and following early pregnancy infections. Large, representative studies addressing these outcomes are needed to better understand the consequences for babies born to women with SARS-CoV-2 in pregnancy. Trial registration PROSPERO ID: CRD42021249818 Strengths and limitations Inclusion of studies of both asymptomatic and symptomatic SARS-CoV-2 infections at any point in pregnancy to maximise generalisability of findings Focus on neonatal outcomes, as opposed to purely obstetric outcomes, to accurately quantify neonatal morbidity Study is limited by available data; important data gap in low-income settings

The COVID19 pandemic has changed women's experiences of pregnancy in the UK (preprint)

Introduction During the SARS-CoV-2 pandemic, maternity care has been substantially altered to reduce transmission of the SARS-CoV-2 virus. Many antenatal services are now restricted or delivered online, and visiting has been restricted during labour and in the postnatal period. Methods We conducted an online survey from 1st August to 31st December 2020 to investigate the experiences of women who were pregnant or breastfeeding in the UK during the SARS-CoV-2 pandemic. The survey included 55 open and closed questions and required 5 minutes to complete. We publicised the survey using social media. Results We received 96 responses, including 66 currently pregnant women and 22 women who were pregnant during the pandemic. The response rate was 70.1% of survey views. We found mixed experiences of the impact of the pandemic on antenatal and perinatal care, notably with some women feeling visiting restrictions were insufficient and others feeling they were too strict. Twenty-nine women received no information about COVID-19, and 6 women found it very difficult to find information. Thirty-nine women would have liked to have more information about breastfeeding after a pregnancy affected by COVID-19, and 37 women wanted more information about antibody persistence and transfer. Discussion Additional support is required for pregnant and lactating women during the current pandemic. Provision of information and support, including via social media, may improve women's experiences of pregnancy in the current environment.

Global research priorities for COVID-19 in maternal, reproductive and child health: results of an international survey (preprint)

Background The World Health Organization's ''Coordinated Global Research Roadmap: 2019 Novel Coronavirus'' outlined the need for research that focuses on the impact of COVID-19 on pregnant women and children. More than one year after the first reported case, significant knowledge gaps remain, highlighting the need for a coordinated approach. To address this need, the Maternal, Newborn and Child Health Working Group (MNCH WG) of the COVID-19 Clinical Research Coalition conducted an international survey to identify global research priorities for COVID-19 in maternal, reproductive and child health. Method This project was undertaken using a modified Delphi method. An electronic questionnaire was disseminated to clinicians and researchers in three different languages (English, French and Spanish) via MNCH WG affiliated networks. Respondents were asked to select the five most urgent research priorities among a list of 17 identified by the MNCH WG. Analysis of questionnaire data was undertaken to identify key similarities and differences among respondents according to questionnaire language, location and specialty. Following elimination of the seven lowest ranking priorities, the questionnaire was recirculated to the original pool of respondents. Thematic analysis of final questionnaire data was undertaken by the MNCH WG from which four priority research themes emerged. Results Questionnaire 1 was completed by 225 respondents from 29 countries. Questionnaire 2 was returned by 49 respondents. The four priority research themes were 1) access to healthcare during the COVID-19 pandemic, 2) the direct and 3) indirect effects of COVID-19 on pregnant and breastfeeding women and children and 4) the transmission of COVID-19 and protection from infection. Conclusion The results of these questionnaires indicated a high level of concordance among continents and specialties regarding priority research themes. This prioritized list of research uncertainties, developed to specifically highlight the most urgent clinical needs as perceived by healthcare professionals and researchers, could help funding organizations and researchers to answer the most pressing questions for clinicians and public health professionals during the pandemic. It is hoped that these identified priority research themes can help focus the discussion regarding the allocation of limited resources to enhance COVID-19 research in MNCH globally.

Indirect Effects of COVID-19 on Maternal, Neonatal, Child, Sexual and Reproductive Health Services in Kampala, Uganda (preprint)

Background: COVID-19 has impacted global maternal, neonatal and child health outcomes. We hypothesised that the early, strict lockdown which severely limited the movements of individuals in Uganda will have impacted access to services. Methods: An observational study, using routinely collected health data from Electronic Medical Records was carried out, utilising data from July 2019 to December 2020 in Kawempe district, Kampala. The mean and 95% confidence intervals were calculated pre-COVID (July 2019-February 2020) and post-COVID (March-December 2020). The means were compared using t-tests, and the monthly totals analysed as to whether they lay within or outside the normal range, compared to the previous 9 months. Results: Antenatal attendances decreased 96% in April 2020 and remain below pre-COVID levels. We found a rise in adverse pregnancy outcomes for Caesarean sections (5%), haemorrhages related to pregnancy (51%), stillbirths (31%) and low-birth-weight (162%) and premature infant births (400%). We noted a drop in neonatal unit admissions, immunisation clinic attendance and delivery of all vaccinations except measles. There was an immediate drop in clinic attendance for prevention of mother to child transmission of HIV (now stabilised) and an increase of 348% in childhood malnutrition clinic attendance. Maternal and neonatal deaths, immediate post-natal care and contraceptive provision remained within normal limits. Conclusion: The response to COVID-19 in Uganda has negatively impacted maternal, child and neonatal health, with the biggest and longest lasting impact seen in complications of pregnancy, stillbirths and low-birthweight infants likely due to delayed care-seeking behaviour. The decline in vaccination clinic attendance has implications for all vaccine-preventable diseases, with a cohort of infants currently unprotected. Further consideration of the impacts of restricting movement and limiting access to preventative services must be undertaken in responding to future pandemics if key maternal and child health services are to be maintained.