The Global Network COVID-19 studies: a review

With the paucity of data available regarding COVID-19 in pregnancy in low- and middle-income countries (LMICs), near the start of the pandemic, the Global Network for Women's and Children's Health Research, funded by the National Institute of Child Health and Human Development (NICHD), initiated four separate studies to better understand the impact of the COVID-19 pandemic in eight LMIC sites. These sites included: four in Asia, in Bangladesh, India (two sites) and Pakistan; three in Africa, in the Democratic Republic of the Congo (DRC), Kenya and Zambia; and one in Central America, in Guatemala. The first study evaluated changes in health service utilisation; the second study evaluated knowledge, attitudes and practices of pregnant women in relationship to COVID-19 in pregnancy; the third study evaluated knowledge, attitude and practices related to COVID-19 vaccination in pregnancy; and the fourth study, using antibody status at delivery, evaluated changes in antibody status over time in each of the sites and the relationship of antibody positivity with various pregnancy outcomes. Across the Global Network, in the first year of the study there was little reduction in health care utilisation and no apparent change in pregnancy outcomes. Knowledge related to COVID-19 was highly variable across the sites but was generally poor. Vaccination rates among pregnant women in the Global Network were very low, and were considerably lower than the vaccination rates reported for the countries as a whole. Knowledge regarding vaccines was generally poor and varied widely. Most women did not believe the vaccines were safe or effective, but slightly more than half would accept the vaccine if offered. Based on antibody positivity, the rates of COVID-19 infection increased substantially in each of the sites over the course of the pandemic. Most pregnancy outcomes were not worse in women who were infected with COVID-19 during their pregnancies. We interpret the absence of an increase in adverse outcomes in women infected with COVID-19 to the fact that in the populations studied, most COVID-19 infections were either asymptomatic or were relatively mild

Factors associated with fresh stillbirths of e 28 weeks of gestation at tertiary care hospital of Pakistan: A case-control study

Every year, 1.3 million fresh stillbirths occur globally. A large number of these fresh stillbirths occur in Sub-Saharan Africa and South Asia. Pakistan has the highest burden of stillbirth and the rate of fresh stillbirth is 14/1000 births which are preventable with appropriate obstetric care. The objective of the study was to determine factors associated with fresh stillbirth among women delivering at? 28 weeks of gestation. Methods: A case-control study was conducted between May to Aug 2019. Cases were the fresh stillborn of \u3e 28 weeks of gestation and control were the livebirths of \u3e 28 weeks of gestation. We enrolled 90 cases and 312 controls in this study. In addition to face to face interviews, the maternal information was also extracted from the patient files. Logistic regression analysis was performed to determine the factors associated with fresh stillbirth. Results: The following factors were found to be associated with an increased risk for fresh stillbirth:no maternal education (AOR 2.46, 95% CI=1.17 — 5.21), not received antenatal care during index pregnancy (AOR 3.11, 95% C1=1.39 — 6.96), recreational substance use (AOR 3.38, 95% CI=1.46 — 7.81), medical illness in index pregnancy (AOR 5.73, 95% CI=2.70 - 12.19), mother who had been referral from other facility (AOR 2.26, 95% CI=-1.06 — 4.82), preterm birth (AOR 2.04, 95% CI-=1.01 — 4.09) and low birth weight (AOR 10.84, 95% CI=5.09 — 23.07). Conclusion: Illitracy, no antenatal care, medical illness in index pregnancy, habit of using recreational substances, preterm and low birth weight were associated with fresh stillbirth

Factors associated with home delivery in rural Sindh, Pakistan: Results from the global network birth registry

Background: According to global estimates for 2017, nearly 295,000 maternal deaths occurred worldwide. Thus, approximately 810 women die every day due to pregnancy-related complications. This burden of maternal deaths in LMICs is primarily due to poor healthcare service utilization, as indicated by relatively low rates of institutional deliveries and skilled-birth attendance (SBA). We conducted this study with an aim to assess the factors associated with home delivery and its subsequent effect on the pregnancy outcome in rural Sindh, Pakistan. Methods: Data for this study were taken from The Global Network\u27s Maternal Newborn Health Registry (MNHR), which is a prospective, population-based observational cohort study. Registry data for 2018-2019 for District Thatta, Pakistan was retrieved for the analysis. Multivariable logistic regression models were used to determine the effect of each independent variable on the place of delivery by including all predictors and covariates. Results of the regression analyses are presented with crude odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Results: A total of 4649 women were included in the study, of these, 1286 (27.7%) women had delivered at home. Of those who delivered at home, a larger proportion was illiterate (90%), had a BMI of less than 18.5 kg/m2 (26.0%), had parity of 3 or more (48.1%), and had a history of pregnancy loss as compared to women who had institutional delivery. In addition, two-thirds of women (63.4%) who had delivered at home had less than 4 ANC visits, whereas 15.6% did not receive any ANC. On multivariable logistic regression we found that home delivery was significantly associated with being illiterate (aOR = 1.60; [95% CI: 1.34, 2.04]), having high parity (aOR = 1.91; [95% CI: 1.58, 2.32]), and no ANC visit (aOR = 14.8; [95% CI: 10.2, 21.5]). Conclusions: More than a quarter of our study sample women delivered at home. These women were illiterate, multiparous, and did not receive antenatal care during pregnancy. It is essential to conduct extensive educational interventions for the women and their family members regarding the potential benefits of delivering in a safe and skilled environment. Moreover, the provision of comprehensive and quality antenatal care should be ensured as it improves the mothers\u27 health-seeking behavior and helps them make informed decisions about their health and well-being

Health care in pregnancy during the COVID-19 pandemic and pregnancy outcomes in six low-and-middle-income countries: Evidence from a prospective, observational registry of the global network for women\u27s and children\u27s health

Objective: On a population basis, we assessed medical care for pregnant women in specific geographic regions of six countries before and during the first year of the COVID-19 pandemic in relationship to pregnancy outcomes.Design: Prospective, population-based study.Setting: Communities in Kenya, Zambia, the Democratic Republic of the Congo, Pakistan, India, and Guatemala.Population: Pregnant women enrolled in the Global Network for Women\u27s and Children\u27s Health\u27s Maternal and Newborn Health Registry METHODS: Pregnancy/delivery care services and pregnancy outcomes in the pre-COVID-19 time-period (March 2019-February 2020) were compared to the COVID-19 time-period (March 2020-February 2021).Main outcome measures: Stillbirth, neonatal mortality, preterm birth, low birth weight, maternal mortality RESULTS: Across all sites, a small but statistically significant increase in home births occurred between the pre-COVID and COVID periods. (18.9% vs 20.3%, aRR 1.12 95% CI 1.05, 1.19). Also, a small but significant decrease in the mean number of antenatal care visits (4.1 - 4.0, p= \u3c0.0001) was seen during the COVID-19 period. Of outcomes evaluated, overall, a small but significant decrease in low-birthweight in the COVID-19 period occurred (15.7% vs 14.6%, aRR 0.94 (0.89, 0.99), but we did not observe any significant differences in other outcomes. There was no change observed in maternal mortality or antenatal haemorrhage overall or at any of the sites.Conclusions: Small but significant increases in home births and decreases in the ANC services were observed during the initial COVID-19 period; however, there was not an increase in the stillbirth, neonatal mortality, maternal mortality, low birth weight or preterm birth rates during the COVID-19 period as compared to the prior year. Further research should help elucidate the relationship between access to and use of pregnancy-related medical services and birth outcomes over an extended period

Knowledge, attitudes, and practices of pregnant women regarding COVID-19 vaccination in pregnancy in 7 low- and middle-income countries: An observational trial from the Global Network for Women and Children\u27s Health Research

Objectives: We sought to determine the knowledge, attitudes and practices of pregnant women regarding COVID-19 vaccination in pregnancy in seven low- and middle-income countries (LMIC).Design: Prospective, observational, population-based study.Settings: Study areas in seven LMICs: Bangladesh, India, Pakistan, Guatemala, Democratic Republic of the Congo (DRC), Kenya and Zambia.Population: Pregnant women in an ongoing registry.Methods: COVID-19 vaccine questionnaires were administered to pregnant women in the Global Network\u27s Maternal Newborn Health Registry from February 2021 through November 2021 in face-to-face interviews.Main outcome measures: Knowledge, attitude and practice regarding vaccination during pregnancy; vaccination status.Results: No women were vaccinated except for small proportions in India (12.9%) and Guatemala (5.5%). Overall, nearly half the women believed the COVID-19 vaccine is very/somewhat effective and a similar proportion believed that the COVID-19 vaccine is safe for pregnant women. With availability of vaccines, about 56.7% said they would get the vaccine and a 34.8% would refuse. Of those who would not get vaccinated, safety, fear of adverse effects, and lack of trust predicted vaccine refusal. Those with lower educational status were less willing to be vaccinated. Family members and health professionals were the most trusted source of information for vaccination.Conclusions: This COVID-19 vaccine survey in seven LMICs found that knowledge about the effectiveness and safety of the vaccine was generally low but varied. Concerns about vaccine safety and effectiveness among pregnant women is an important target for educational efforts to increas

Knowledge, attitude and practices of pregnant women related to COVID-19 infection: A cross-sectional survey in seven countries from the global network for women\u27s and children\u27s health

Objective: We sought to understand knowledge, attitudes and practices (KAP) regarding COVID-19 in pregnant women in seven low and middle-income countries (LMIC). Design: Population-based prospective, observational study. Settings: Study sites in DRC, Kenya, Zambia, Bangladesh, India (two sites), Pakistan and Guatemala. Population and sample: Pregnant women in the Global Network\u27s Maternal and Neonatal Health Registry (MNHR). Methods: A KAP questionnaire was administered in face-to-face interviews with pregnant women from September 2020 through October 2021 in the MNHR. Main outcome measures: KAP regarding COVID-19 during pregnancy. Results: In all, 25 260 women completed the survey. Overall, 56.8% of women named ≥3 COVID-19 symptoms, 34.3% knew ≥2 transmission modes, 51.3% knew ≥3 preventive measures and 79.7% named at least one high-risk condition. Due to COVID-19 exposure concerns, 23.8% had avoided prenatal care and 7.5% planned to avoid hospital delivery. Over half the women in the Guatemalan site and 40% in the Pakistan site reduced care seeking due to COVID-19 exposure concerns. Of the women, 24.0% were afraid of getting COVID-19 from healthcare providers. Overall, 63.3% reported wearing a mask and 29.1% planned to stay at home to reduce COVID-19 exposure risk. Conclusions: We found a decrease in planned antenatal and delivery care use due to COVID-19 concerns. The clinical implications of potential decreases in care are unclear, but decline in essential healthcare utilisation during pregnancy and delivery could pose challenges for maternal and newborn health. More research is needed to address the impact of COVID-19 on routine pregnancy and delivery care

The Global network COVID-19 studies: A review

With the paucity of data available regarding COVID-19 in pregnancy in low- and middle-income countries (LMICs), near the start of the pandemic, the Global Network for Women\u27s and Children\u27s Health Research, funded by the National Institute of Child Health and Human Development (NICHD), initiated four separate studies to better understand the impact of the COVID-19 pandemic in eight LMIC sites. These sites included: four in Asia, in Bangladesh, India (two sites) and Pakistan; three in Africa, in the Democratic Republic of the Congo (DRC), Kenya and Zambia; and one in Central America, in Guatemala. The first study evaluated changes in health service utilisation; the second study evaluated knowledge, attitudes and practices of pregnant women in relationship to COVID-19 in pregnancy; the third study evaluated knowledge, attitude and practices related to COVID-19 vaccination in pregnancy; and the fourth study, using antibody status at delivery, evaluated changes in antibody status over time in each of the sites and the relationship of antibody positivity with various pregnancy outcomes. Across the Global Network, in the first year of the study there was little reduction in health care utilisation and no apparent change in pregnancy outcomes. Knowledge related to COVID-19 was highly variable across the sites but was generally poor. Vaccination rates among pregnant women in the Global Network were very low, and were considerably lower than the vaccination rates reported for the countries as a whole. Knowledge regarding vaccines was generally poor and varied widely. Most women did not believe the vaccines were safe or effective, but slightly more than half would accept the vaccine if offered. Based on antibody positivity, the rates of COVID-19 infection increased substantially in each of the sites over the course of the pandemic. Most pregnancy outcomes were not worse in women who were infected with COVID-19 during their pregnancies. We interpret the absence of an increase in adverse outcomes in women infected with COVID-19 to the fact that in the populations studied, most COVID-19 infections were either asymptomatic or were relatively mil

COVID-19 symptoms and antibody positivity among unvaccinated pregnant women: An observational study in seven countries from the global network

Objective: To determine the relation of COVID-19 symptoms to COVID-19 antibody positivity among unvaccinated pregnant women in low- and middle-income countries (LMIC).Design: COVID-19 infection status measured by antibody positivity at delivery was compared with the symptoms of COVID-19 in the current pregnancy in a prospective, observational cohort study in seven LMICs.Setting: The study was conducted among women in the Global Network for Women\u27s and Children\u27s Health\u27s Maternal and Newborn Health Registry (MNHR), a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (Belagavi and Nagpur sites) and Guatemala.Population: Pregnant women enrolled in the ongoing pregnancy registry at study sites.Methods: Data on COVID-19 symptoms during the current pregnancy were collected by trained staff between October 2020 and June 2022. COVID-19 antibody testing was performed on samples collected at delivery. The relation between COVID-19 antibody positivity and symptoms was assessed using generalised linear models with a binomial distribution adjusting for site and symptoms.Main outcome measures: COVID-19 antibody status and symptoms of COVID-19 among pregnant women.Results: Among 19 218 non-vaccinated pregnant women who were evaluated, 14.1% of antibody-positive women had one or more symptoms compared with 13.4% in antibody-negative women. Overall, 85.3% of antibody-positive women reported no COVID-19 symptoms during the present pregnancy. Reported fever was significantly associated with antibody status (relative risk [RR] 1.10, 95% CI 1.03-11.18; P = 0.008). A multiple variable model adjusting for site and all eight symptoms during pregnancy showed similar results (RR 1.13, 95% CI 1.04-1.23; P = 0.012). None of the other symptoms was significantly related to antibody positivity.Conclusions: In a population-based cohort in LMICs, unvaccinated pregnant women who were antibody-positive had slightly more symptoms during their pregnancy and a small but significantly greater increase in fever. However, for prevalence studies, evaluating COVID-19-related symptoms does not appear to be useful in differentiating pregnant women who have had a COVID-19 infection

Health Care in Pregnancy During the COVID-19 Pandemic and Pregnancy Outcomes in Six Low-and-Middle-Income Countries: Evidence from a Prospective, Observational Registry of the Global Network for Women's and Children's Health

OBJECTIVE: On a population basis, we assessed medical care for pregnant women in specific geographic regions of six countries before and during the first year of the COVID-19 pandemic in relationship to pregnancy outcomes. DESIGN: Prospective, population-based study. SETTING: Communities in Kenya, Zambia, the Democratic Republic of the Congo, Pakistan, India, and Guatemala. POPULATION: Pregnant women enrolled in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry METHODS: Pregnancy/delivery care services and pregnancy outcomes in the pre-COVID-19 time-period (March 2019-February 2020) were compared to the COVID-19 time-period (March 2020-February 2021). MAIN OUTCOME MEASURES: Stillbirth, neonatal mortality, preterm birth, low birth weight, maternal mortality RESULTS: Across all sites, a small but statistically significant increase in home births occurred between the pre-COVID and COVID periods. (18.9% vs 20.3%, aRR 1.12 95% CI 1.05, 1.19). Also, a small but significant decrease in the mean number of antenatal care visits (4.1 - 4.0, p= <0.0001) was seen during the COVID-19 period. Of outcomes evaluated, overall, a small but significant decrease in low-birthweight in the COVID-19 period occurred (15.7% vs 14.6%, aRR 0.94 (0.89, 0.99), but we did not observe any significant differences in other outcomes. There was no change observed in maternal mortality or antenatal haemorrhage overall or at any of the sites. CONCLUSIONS: Small but significant increases in home births and decreases in the ANC services were observed during the initial COVID-19 period; however, there was not an increase in the stillbirth, neonatal mortality, maternal mortality, low birth weight or preterm birth rates during the COVID-19 period as compared to the prior year. Further research should help elucidate the relationship between access to and use of pregnancy-related medical services and birth outcomes over an extended period