COVID-19 and preterm birth – Authors' reply

We thank Laura Magee and colleagues for providing their feedback on our Comment.¹ Indeed, the reduction in the number of referrals to emergency obstetric care was more alarming than the overall decrease in the number of hospital admissions for management of pregnancy. This reduction in emergency referrals could be due to reluctance by the patient or their caregiver for timely referral to tertiary care in non-urgent cases when suggested by the treating doctor at primary and secondary health-care centres. The fear of contracting COVID-19 at tertiary health-care centres (mostly in overcrowded cities) overshadowed the willingness of patients to seek care at these centres. An absence of public transport during lockdown augmented the plight of pregnant women requiring referral, as most patients in India still use public transport for emergency visits.

The proportion of babies born preterm (ie, before 37 weeks gestation) in our institute increased from 8·3% (514 of 6209) in the pre-lockdown period to 10·4% (367 of 3527) in the post-lockdown period. Similar findings were also reported in Nepal, with an almost identical patient demography and health-care system to India.² The proportion of cases of preterm labour that were spontaneous increased from 63% (326 of 514) in the pre-lockdown cohort to 67% (246 of 367) in the lockdown cohort, and the proportion of cases of preterm premature rupture of membranes increased from 24% (124 of 514) in the pre-lockdown cohort to 26% (95 of 367) in the lockdown cohort. These observations were probably due to the increased proportion of women at a high risk of complications with care-seeking behaviour. By contrast, the proportion of iatrogenic preterm births decreased from 13% (64 of 514) in the pre-lockdown cohort to 7% (26 of 367) in the lockdown cohort. The drastic reduction in the number of antenatal visits pre-lockdown compared with post-lockdown might have led to a decrease in the identification of pregnancies requiring medically indicated preterm birth, resulting in a decreased proportion of iatrogenic preterm births.