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(Not) Giving Women Good Sex

April 5, 2021

Is this fraud?

My colleague, Susan Bewley, drew my attention to the Journal of Sex Research last week (click here or Spielmans 2020 Re Analyzing Phase III Bremelanotide Trials for Hypoactive Sexual Desire Disorder in Women). The author, Glen Spielmans, Professor of Psychology at Metropolitan State University in Minnesota, dissects two pivotal phase-3 trials (click here or Kingsberg Obstetrics & Gynecology November 2019), which had led the US Federal Drug Administration (FDA) to license bremelanotide, trade name Vyleesi, to treat women with hypoactive sexual desire disorder (HSDD).

One of the original co-primary outcomes in each trial was switched, many pre-specified outcomes went unreported and new ones appeared, scores were reported as dichotomous rather than as the prespecified means, cut-off values varied for no apparent reason, and other outcomes were claimed as supportive without data. Spielmans also noted that more women (18 or 19% bremelanotide v 3 or 9% placebo) dropped out of the active groups, and questioned whether the various shifts in subsets of sexual behaviour scores, even in the unlikely event they were real, were of clinical significance.

He is correct on all counts. But altered co-primary outcomes in two drug licensing trials? How did that get past the FDA?

Background

Bremelanotide is a polypeptide, related to melanocyte stimulating hormone (MSH). Ever since someone noticed in the 1960s that MSH caused rats to become sexually aroused, chemists have been fiddling with the pharmacology in the hope of creating a female Viagra. In 2016, Palatin Technologies, who own the rights, convinced themselves in a phase-2 dose-finding trial (PT-141-54 in the FDA report) (click here or clayton 2016) that the stuff worked at higher doses. The planned sample size was 100 per group. The pre-specified primary outcome was change in satisfying sexual events (SSE) per month.

PlaceboLow doseMediumHigh dose
No. randomised 99 100 9999 
Analysed (at least 1 dose & 1 follow-up visit)  91 87 7574 
Dropped out 8 1324 25 
Additional satisfying sexual events per month 0.2 0.6 0.7 0.8

The authors claimed a dose response relationship (bottom row) but were coy about the row above – I’ve extracted it for you. Without knowing what they were getting, three times as many women on the higher doses dropped out. In a double-blind trial this can only mean one thing, side effects. There were many more, mainly nausea, flushing and headache, in the active treatment groups

Such non-random differential drop out pretty much invalidates the results. If women who stayed the course were more stoical, or had a greater desire for their sexual problems to be sorted, it’s hardly surprising to see a small increase in SSEs.

But what do I know? These data were judged sufficiently promising to set up two pivotal efficacy trials for FDA approval. 

The trials

Both had the same title “Study to Evaluate the Efficacy/Safety of Bremelanotide in Premenopausal Women With Hypoactive Sexual Desire Disorder (HSSD)” on Clinicaltrials.gov.

They both studied the allegedly most effective, high dose of bremelanotide, 1.75mg, from the dose-finding study.

They were both reported in the same paper (click here or Kingsberg Obstetrics & Gynecology November 2019). For the FDA analysis (click here or FDA bremelanotide).

Study 1 (labelled BMT-301 in Kingsberg and FDA papers) had a planned sample size of 550 (actual 723) and ran from December 2014 to July 2016, (registry here). Study 2 (labelled BMT-302) had the same planned sample size of 550 (actual 714) and ran from January 2015 to August 2016, (registry here). I could find no explanation for the 30% sample size increases, in either the Kingsberg paper or the FDA report.

Despite their identical eligibility criteria, and almost identical recruitment periods, both trials appear to have been run in the same 91 centres.

The original co-primaries for both trials were:

1.       Change in Female Sexual Function Index–desire domain (FSFI-D). The desire domain is the sum of; “Over the past 4 weeks, how often did you feel sexual desire or interest?” – responses range from 1 “Almost never or never” to 5 “Almost always or always” – and; “Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?” – responses range from 1 “Very low or none at all” to 5 “Very high”.

2.       Change in absolute number of sexually satisfying events (SSE) per month.

Of thirteen planned secondary outcomes, the twelfth was this question from the Female Sexual Distress Scale–Desire/Arousal/Orgasm (FSDS-DAO); “are you bothered by low sexual desire?” Responses range from 0 “never” to 4 “always”.

Both trial results would have been negative had the co-primary outcomes remained unchanged. Although absolute numbers of SSEs are not reported in either the paper nor the FDA report, the latter states “neither treatment nor placebo arm showed any improvement” (p 126).

This looks suspicious. SSEs are more meaningful than “bothered by low sexual desire” which is little more than a different aspect of the other co-primary.

But on 27 October 2014 (click here) the FDA had held a workshop with patients about Female Sexual Dysfunction.

The company claimed that workshop participants had stated that SSEs were a poor efficacy outcome. Some quotations e.g. “Several [participants] stressed the importance of feeling desire regardless of whether it is accompanied by a satisfying sexual event” (p6), could be interpreted this way, although others e.g. “Participants largely appeared to believe that having satisfying sexual events was important to them” (p13) suggest the opposite. Even on its own terms this is hardly a convincing argument.

But the workshop had been captured by pharma. Here’s what independent experts, Leonore Tiefer, Ellen Laan and Rosemary Basson wrote about it at the time (click here or Tiefer),

Participants had their expenses paid by [a group funded by] pharmaceutical companies, […] had met the morning of the first day in their hotel to hear presentations and prepare their talking points.

They had each received a green shawl, identifying them with the ‘’even the score’’ campaign that accused the FDA of sexism in handling [female sexual disorder] drug applications [and] arrived at and departed together by chartered bus.

It looks like the FDA was pressured into agreeing the switch, to avoid accusations of sexism in the way they treated applications for female and male sexual treatments.

And the timing of the switch? The alteration was requested on 10 October 2016. Study BMT-301 had been completed on July 26 that year, and study BMT-302 on Aug 4th.

Let’s summarise. More than two months after the studies had been completed, on the basis of a dodgy, pharma-captured workshop conducted two years earlier, the trial sponsors persuaded the FDA to allow the co-primary endpoints to be switched. They were changed from a meaningful predefined outcome justified by the pilot dose-finding study, the number of satisfying sexual events, to the twelfth of thirteen secondary outcomes. And guess what? Bremelanotide, which did not alter the number of satisfying sexual events, magically improved this suddenly important secondary outcome.

Spielmans doesn’t say it, but I do. This must be a data-driven outcome switch. If so, that’s fraud. 

Jim Thornton

Update 10 April 2021

Yesterday Dr Kingsberg and her colleagues replied to Dr Spielmans’ critique (click here or paper), and Dr Spielmans replied to her reply (click here or paper). Despite much bluster, in my opinion, she failed to deal with any of his substantive points. But judge for yourself.

With regard to whether the co-primary outcome switch was data driven, Kingsberg writes;

He also alludes to “data peeking” in his introduction and that the FDA allowed the “sponsor’s request for satisfying sexual events (SSEs) to move from the co-primary to the key secondary outcome …. a year after the trials had begun.” What Spielmans omitted is that the FDA published a guidance document (2016) for designing clinical trials in which SSEs were no longer required to be a primary endpoint for HSDD treatment trials. Instead, trials could now include measures reflecting the hallmark criteria of the condition: loss of (i.e., deficiency or absence of) sexual desire (i.e., FSFI-D) and distress about lack of desire (i.e., FSDS-DAO #13). The approval from the FDA to change the primary endpoint, after discussion with the FDA review division, came prior to the data lock [my emphasis] in these well-conducted, randomized, double-blind, multicenter placebo-controlled trials, with pre-established statistical analysis plans. 

Note the non-denial choice of words. No-one doubts that the outcome switch came “prior to the data lock”. The issue is whether the sponsor had seen the data prior to the outcome switch request.

Philosophy for children P4C2 – clarification

March 11, 2021

The power of randomisation

Mistake in my P4C-2 post yesterday (click here). The result is still negative, and the report still turgid, but when describing the distribution of the pooled reading and maths scores, I suggested that the authors had not shown them by group, and made the snide comment “Perish the thought that an educationalist would ever show you anything remotely near to the raw data!”

Forgive me. Further down appendix I of the main report (click here) are “intervention” (p 100) and, controls (p 102). But different pages? This is a randomised trial where half the pupils got philosophy teaching and half did not. Readers want to compare the two groups side by side. Come on EEF!

To help I’ve reordered the graphs here p4c2 result histograms p number. Intervention group left, control right. Page one, free school meal (FSM) pupils and page two all pupils. Reading scores before maths scores.

It’s rather revealing. For each outcome and for each subgroup not only are the means and ranges almost identical but also the shapes of the distributions. Not exactly identical – these are different populations – but remarkably similar. Go on, check. Click the link above and then scroll down comparing left to right. The shape of the control distribution of reading scores among FSM pupils is different from the shape of the control maths scores, but both are almost identical to the respective reading and maths scores for the intervention group.  Same for the whole sample.

Not only did the intervention, Philosophy for Children, have no effect on maths or reading but, since it had no effect, we can see how beautifully, when you have a large sample size, randomisation really does generate comparable groups.

Well I think it beautiful.

Jim Thornton

 

Philosophy for Children (P4C) – trial 2

March 9, 2021

Still doesn’t work. Really doesn’t. Not even a tiny benefit.

Five years ago a rather nice randomised trial, run by the Education Endowment Foundation (EEF) (click here), tested the effect on reading and writing, of teaching philosophy to primary school children. The result was negative, but unwisely the EEF entrusted evaluation to a group of educationalists who were determined to find a positive result. By ignoring their original analysis plan, doing a data-driven analysis of change scores, and picking a favourable subgroup, children entitled to free school meals, they managed to convince themselves that teaching little children to be kind to their teddy bears helped wth reading and maths (click here for my analysis of where they went wrong). The newspapers picked up the story and headlines flew round the world (click here).

Fortunately I wasn’t the only one to smell a rat (see here and here). Professor Gorard, the lead evaluator, sent me a patronising email and blocked me on social media, but the EEF did the right thing. They realised they’d boobed, decided not to published the misleading analysis in a peer-reviewed journal [but see footnote], and did the trial again. The results are just in (website here, main report here, or for those with access problems Philosophy_for_Children_report_-_final_-_pdf).

The second trial, P4C-2, was also a cluster design but larger, 75 intervention and 123 control schools, compared with the original trial’s 26 intervention and 22 control. The protocol (click here) and analysis plan (click here) were published and adhered to. The biggest risk with cluster trials is differential recruitment or measurement of outcomes related to knowing the cluster, but this was avoided by using the 2019 Key Stage 2 (KS2) reading scale score as the primary outcome. KS2 reading and maths are measured independently on all pupils in the country, whether or not they or their schools participated. Since Gorard’s data dredging had shown the most “benefit” among children receving free school meals, the primary analysis was planned for this group.  Analysis was by intention to treat.

The report is 125 pages long, and a turgid read, – education researchers love making simple things complicated – but the essence is easy to describe. There is a CONSORT flow diagram (Fig 1, p33 not shown here), few pupils were lost to follow-up (Table 12, p36 not shown here), and the randomisation achieved a balance of both schools and pupils at baseline (Table 13, p37 not shown here). The primary and main secondary outcomes are in Table 14, p38 (click on thumbnail to read).

The presentation is rather strange. For each group they report the mean score and the 95% confidence interval for the mean. The actual score distributions are relegated to appendix I, p98.

Don’t be mislead by the words intervention and control into reading these as distributions by group.  Perish the thought that an educationalist would ever show you anything remotely near to the raw data!  These are pooled results for reading and maths, each for the whole sample and the free school meals subgroup; four distributions in total. They tell us nothing about the effect of the intervention, but they allow the reader to see that scores are roughly normally distributed with mean values between 100 and 105, a range of 80-120 and a standard deviation of roughly 12.

Turning back to table 14 above we can see that the absolute mean differences between group are tiny fractions of a single score point, i.e trivial.  The Hedges g column expresses the difference as a fraction of the pooled standard deviation. Tiny by any standards. Even those educationalists who prefer the effect size to significance testing, ignore effect sizes of <0.2 and generally only consider one of >0.4 as “meaningful”. These are 0.01 to 0.05. For frequentists like me, despite the large sample size, the result is not remotely “statistically significant”.

The rest of the report discusses how well various schools implemented the intervention and searches for a signal related to how well P4C was implemented, but finds nothing.

In summary a well-designed and well-analysed negative trial. We can be confident of the result, and confident also that the trial has not missed a worthwhile small effect.

Some Twitter commenters have said, “But surely we don’t teach moral philosophy to help chidren with reading or maths. We do it to help them grow up to be better kinder people.” They make a good point. The trial says nothing about the effect of P4C on moral behaviour, and everyone supports primary school teachers continuing to teach their pupils to be kind and honest. But education planners should stop paying large sums to Sapere, the creator of P4C, and displacing lessons to teach it, in the hope of improving reading and maths.

It’s a ground-breaking trial

I wonder where it will get published. In my field a negative, large well-conducted cluster trial like this, – the AFFIRM trial of encouraging awareness of fetal movements in pregnancy for example – doesn’t languish in an obscure specialist journal but gets published as a full length paper in the most prestigious medical journal in the world, The Lancet (click here). This report will need a rewrite, but a major general science journal, Science or Nature, should publish it for its methodological importance.

The EEF has shown how to evaluate an educational intervention properly. Imagine if they used the same methods to compare phonics with whole language to teach reading, or to test whether drilling children in tables was helpful or harmful. Imagine that!

Jim Thornton

Footnote added 13 March. I’d missed it. The EEF did publish the misleading analysis in a peer reviewed journal, (click here or 1467-9752.12227), albeit with weaker conclusions. “… for […] attainment outcomes in the short term, an emphasis on developing reasoning is promising, especially for the poorest students, but perhaps not the most effective way forward.”

The singer, the painter & the randy politician

February 8, 2021

Ann Ford by Thomas Gainsborough

   

It’s 1760. Bath is booming. The agricultural revolution has increased the population, and created a new class of landed gentry, but the industrial revolution has hardly started. Coal is mined locally, the town is dirty and smoky, and there are no canals, let alone railways. Just stage coaches along the fast but dangerous new turnpikes, often past the bodies of hanged highwaymen. But Bath is fashionable. Wealthy gentry move their households to the first English spa town for the winter season. Gainsborough, facing stiff competition in London, decides to try his hand. This is his advertisement.

21-year-old Ann Ford had started singing privately at her father’s house in London, but has had to run away to Bath to sing in public. She is good, but the crowds titter at a woman behaving so outrageously. Philip Thicknesse, Gainsborough’s mentor, and later Ann’s husband, sets up a meeting, and soon the six foot painting stands in the front window of Gainsborough’s studio. The silvery dress attracts attention and the pose is exciting. No well brought up woman crosses her legs in public! As one future customer notes “a most extraordinary figure, handsome and bold; but I should be very sorry to have any one I loved set forth in that manner.” The viola da gamba, a man’s instrument, peeping out from behind the red curtain, refers to the latest scandal .

William Villiers, the 52-year-old Earl of Jersey, wants Ann, and offers her the extraordinary sum of £800 a year to be his mistress, with the promise of marriage when his ailing wife dies. Not only does she refuse, but when he tries to sabotage her first public concert in retaliation, she publishes a pamphlet, A Letter from Miss F—d to a Person of Distinction, defending her position.  Amazingly Villiers replies, and a juicy pamphlet war ensues – the Kim Kardashian of Bath scrapping with a publicity hungry politician. Fun for all, and great for Gainsborough. His career thrives.

The painting is now in the Cincinnati Art Museum (click here).

Jim Thornton

Above mostly from Gainsbrough; a portrait by James Hamilton. Weidenfield & Nicholson, London 2017.

Covid-19 vaccines, pregnancy & fertility

January 14, 2021

Primary sources

Primary scientific reports of clinical data on the safety and effectiveness of SARS-CoV-2 vaccines in pregnancy, and in women of childbearing age. In reverse order. Regularly updated. Click here for ripe-tomato.org’s Covid-19 navigation page. Thank you Susan Bewley and Keelin O’Donoghue for getting this started. Click here for “Vaccine in pregnancy news reports“.  We are not providing running totals by vaccine or control group but Viki Male @VikiLovesFACS is doing so here. .

Update 14 June – sources 43 and 44 added

Source 44 – 38 vaccinated pregnant health-care workers

Twenty got Pfizer-BioNTech, and 18 Moderna (click here or source). Pregnancy-related events (gestational hypertension (1), threatened labor (1), miscarriage (1), premature delivery (1) from the Pfizer-BioNTech group and none from the Moderna group. Self-reported via SurveyMonkey. Citation: Kalyan Kadali RA, Janagama R, Peruru SR, Racherla S, Tirumala R, Madathala RR, Gajula V, Adverse effects of COVID-19 mRNA vaccines among pregnant women: A cross-sectional study on healthcare workers with detailed self-reported symptoms, American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2021.06.007.

Source 43 – Case report from Italy

A 42-year-old pregnant healthcare worker received the Comirnaty (Pfizer/BioNTech) mRNA vaccination at 31 and 34 weeks (click here or source). Cord blood antibodies were present. The hospital is not named but the authors came from Firenze, Italy. Citation: Riviello C, Pontello V. Maternal and neonatal SARS-CoV-2 antibodies assessment after mRNA maternal vaccination in the third trimester of pregnancy. Int J Gynaecol Obstet. 2021 Jun 11. doi: 10.1002/ijgo.13783. Epub ahead of print. PMID: 34115887.

Update 8 June – sources 40 to 42 added

Source 42 – 14 lactating women from Portugal

All vaccinated with Pfizer BNT162b2 mRNA (click here or source). From Centro Hospitalar Universitário Lisboa Central. Citation: Juliana Gonçalves, A. Margarida Juliano, Nádia Charepe, Marta Alenquer, Diogo Athayde, Filipe Ferreira, Margarida Archer, Maria João Amorim, Fátima Serrano, Helena Soares. Non-neutralizing secretory IgA and T cells targeting SARS-CoV-2 spike protein are transferred to the breastmilk upon BNT162b2 vaccination. medRxiv 2021.05.03.21256416; doi: https://doi.org/10.1101/2021.05.03.21256416

Source 41 – 6 lactating women from USA

Five vaccinated with BNT162b2 (Pfizer) and one with mRNA-1273 (Moderna) (click here or source). From University of California, San Francisco. Citation: Yarden Golan, Mary Prahl, Arianna Cassidy, Christine Y. Lin, Nadav Ahituv, Valerie J. Flaherman, Stephanie L. Gaw. COVID-19 mRNA vaccine is not detected in human milk. medRxiv 2021.03.05.21252998; doi: https://doi.org/10.1101/2021.03.05.21252998

Source 40 – 122 vaccinated women from USA

Eighty five had Pfizer-BioNTech, & 37 Moderna (click here or source). From Weill Cornell Medicine, New York. Citation: Malavika Prabhu, Elisabeth A. Murphy, Ashley C. Sukhu, Jim Yee, Sunidhi Singh, Dorothy Eng, Zhen Zhao, Laura E. Riley, Yawei J. Yang. Antibody response to SARS-CoV-2 mRNA vaccines in pregnant women and their neonates. bioRxiv 2021.04.05.438524; doi: https://doi.org/10.1101/2021.04.05.438524

Update 7 June – source 39 added

Source 39 – 86 vaccinated pregnant women from Israel

From eight Israeli hospitals (click here or source). Compared with 65 pregnant women who had had Covid – see study 714. Citation: Beharier O, Plitman Mayo R, Raz T, Nahum Sacks K, Schreiber L, Suissa-Cohen Y, Chen R, Gomez-Tolub R, Hadar E, Gabbay-Benziv R, Jaffe Moshkovich Y, Biron-Shental T, Shechter-Maor G, Farladansky-Gershnabel S, Yitzhak Sela H, Benyamini-Raischer H, Sela ND, Goldman-Wohl D, Shulman Z, Many A, Barr H, Yagel S, Neeman M, Kovo M. Efficient maternal to neonatal transfer of antibodies against SARS-CoV-2 and BNT162b2 mRNA COVID-19 vaccine. J Clin Invest. 2021 May 20:150319. doi: 10.1172/JCI150319. Epub ahead of print. PMID: 34014840.

Update 6 June – source 38 added

Source 38 – 47 vaccinated women undergoing IVF in Israel

Forty seven women underwent IVF and ICSI, both before and after BNT162b2 COVID-19 vaccination (click here or source). There were no major differences between the pre- and post-vaccination cycles. They were cared for at the Hadassah Hebrew-University Medical Center in Jerusalem. Citation: Myriam Safrai, Amihai Rottenstreich, Shmuel Herzberg, Tal Imbar, Benjamin Reubinoff, Assaf Ben-Meir. Stopping the misinformation: BNT162b2 COVID-19 vaccine has no negative effect on women’s fertility. medRxiv 2021.05.30.21258079; doi: https://doi.org/10.1101/2021.05.30.21258079

Update 3 June – sources 36 and 37 added

Source 37 – four pregnant & four breast-feeding women vaccinated

These authors report a convenience sample (overweight on health workers) of women who responded to an online survey in January 2021 (click here or source). 87/656 (13%) of non-pregnant, 4/216 (1.9%) of pregnant, and 4/122 (3.3%) of breast-feeding respondents had been vaccinated. Citation: Desmond Sutton, Mary D’Alton, Yijia Zhang, Ka Kahe, Ana Cepin, Dena Goffman, Anna Staniczenko, Hope Yates, Anna Burgansky, Jaclyn Coletta, Zev Williams, Cynthia Gyamfi-Bannerman, COVID-19 Vaccine Acceptance Among Pregnant, Breastfeeding and Non-pregnant Reproductive Aged Women, American Journal of Obstetrics & Gynecology MFM (2021), doi: https://doi.org/10.1016/j.ajogmf.2021.100403

Source 36 – interim report of S African Ad26.COV2.S vaccine study

This interim report (click here or source) of adverse thromboembolic events in the ongoing Sisonke study of the Ad26.COV2.S (Janssen) vaccine (NCT04838795) includes a a 38-year-old woman who had given birth to twins nine months before vaccination and presented with features of transient ischemic attack 8 days post vaccination. Citation: Simbarashe Takuva,Azwidhwi Takalani, Nigel Garrett, Ameena Goga, Jonny Peter, Vernon Louw, Jessica Opie, Barry Jacobson, Ian Sanne, Linda Gail‑Bekker, Glenda Gray. Thromboembolic Events in the South African Ad26.COV2.S Vaccine Study. NEJM. June 2, 2021 DOI: 10.1056/NEJMc2107920

Update 29 May – source 35 added

Source 35 – two pregnant and five breast-feeding women

The authors for this MedRxiv preprint report 15 women (two pregnant, five breast feeding) who received at least one dose of the BNT162B2 vaccine (click here or source). None of them showed any cross reactivity to human syncytin-1. Nor was any mRNA detected in breast milk. Citation: Citra NZ Mattar, Winston Koh, Yiqi Seow, Shawn Hoon, Aparna Venkatesh, Pradip Dashraath, Li Min Lim, Judith Ong, Rachel Lee, Nuryanti Johana, Julie SL Yeo, David Chong, Lay-Kok Tan, Jerry Chan, Mahesh Choolani, Paul Anantharajah Tambyah. Addressing anti-syncytin antibody levels, and fertility and breastfeeding concerns, following BNT162B2 COVID-19 mRNA vaccination. medRxiv 2021.05.23.21257686; doi: https://doi.org/10.1101/2021.05.23.21257686

Update 27 May – source 34 added

Source 34 – Ten pregnant women in Chinese vaccine (WIV04 and HB02) trial

In this interim analysis of a randomised trial (40,382 participants), conducted in six centres in the Middle East, of two SARS-Cov-2 vaccines (WIV04 and HB02) 5 pregnant women received the first dose of the WIV04 vaccine, 2 the HBO2 vaccine, and 3 placebo (click here or source). No pregnancy outcomes are reported. The vaccines were developed by the Wuhan Institute of Biological Products Co, Ltd, and the Beijing Institute of Biological Products Co, Ltd, both of which belong to the China National Biotec Group Company Limited. The trial centres were Sheikh Khalifa Medical City in Abu Dhabi and the Al Qarain Health Center in Sharjah, both in the United Arab Emirates (UAE); the Salmanyia Medical Complex in Bahrain; Vacsera Medical Center and Katameya Medical Center in Egypt; and Prince Hamza Hospital in Jordan. Citation: Al Kaabi N, Zhang Y, Xia S, et al. Effect of 2 Inactivated SARS-CoV-2 Vaccines on Symptomatic COVID-19 Infection in Adults: A Randomized Clinical Trial. JAMA. Published online May 26, 2021. doi:10.1001/jama.2021.8565

Update 26 May – source 33 added

Source 33 – no pregnancies among three cases of Astra Zeneca VITT

There were no pregnant women among three cases (two women of childbearing age) of ischemic stroke associated with vaccine-induced immune thrombotic thrombocytopaenia (VITT) after the Astra Zeneca ChAdOx1 nCoV-19 vaccine (click here or source). See also Source 27. These case are probably not included in Source 27. Citation: Al-Mayhani T, Saber S, Stubbs MJ, et alIschaemic stroke as a presenting feature of ChAdOx1 nCoV-19 vaccine-induced immune thrombotic thrombocytopaeniaJournal of Neurology, Neurosurgery & Psychiatry Published Online First: 25 May 2021. doi: 10.1136/jnnp-2021-326984

Update 24 May – source 32 added

Source 32 – Birth outcomes for 140 women vaccinated in pregnancy

MedRxiv preprint. Cases collected by the Mayo clinic (click here or source). Citation: Regan N. Theiler, Myra Wick, Ramila Mehta, Amy Weaver, Abinash Virk, Melanie Swift. Pregnancy and birth outcomes after SARS-CoV-2 vaccination in pregnancy. medRxiv 2021.05.17.21257337; doi: https://doi.org/10.1101/2021.05.17.21257337

Update 15 May – sources 30 and 31 added

Source 31 – USA. 84 vaccinated pregnant women and controls

From author affiliations identified through Feinberg School of Medicine, and the Ann and Robert H. Lurie Children’s Hospital of Chicago, Illinois (click here or source). Citation: Shanes ED, Otero S, Mithal LB, Mupanomunda CA, Miller ES, Goldstein JA. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vaccination in Pregnancy: Measures of Immunity and Placental Histopathology. Obstet Gynecol. 2021 May 11. doi: 10.1097/AOG.0000000000004457. Epub ahead of print. PMID: 33975329.

Source 30 – USA. 30 pregnant and 16 lactating vaccinated women

Identified through the Beth Israel Deaconess Medical Center, Boston, Massachusetts (click here or source). Citation: Collier AY, McMahan K, Yu J, Tostanoski LH, Aguayo R, Ansel J, Chandrashekar A, Patel S, Apraku Bondzie E, Sellers D, Barrett J, Sanborn O, Wan H, Chang A, Anioke T, Nkolola J, Bradshaw C, Jacob-Dolan C, Feldman J, Gebre M, Borducchi EN, Liu J, Schmidt AG, Suscovich T, Linde C, Alter G, Hacker MR, Barouch DH. Immunogenicity of COVID-19 mRNA Vaccines in Pregnant and Lactating Women. JAMA. 2021 May 13. doi: 10.1001/jama.2021.7563. Epub ahead of print. PMID: 33983379.

Update 6 May – source 29 added

Source 29 – five pregnancies in Novavax vaccine trial in South Africa

Two women became pregnant after their first dose in the vaccine arm and three in the control, in this trial of the Novavax NVX-CoV2373 vaccine (click here or source). Citation: Shinde V, Bhikha S, Hoosain Z, Archary M, Bhorat Q, Fairlie L, Lalloo U, Masilela MSL, Moodley D, Hanley S, Fouche L, Louw C, Tameris M, Singh N, Goga A, Dheda K, Grobbelaar C, Kruger G, Carrim-Ganey N, Baillie V, de Oliveira T, Lombard Koen A, Lombaard JJ, Mngqibisa R, Bhorat AE, Benadé G, Lalloo N, Pitsi A, Vollgraaff PL, Luabeya A, Esmail A, Petrick FG, Oommen-Jose A, Foulkes S, Ahmed K, Thombrayil A, Fries L, Cloney-Clark S, Zhu M, Bennett C, Albert G, Faust E, Plested JS, Robertson A, Neal S, Cho I, Glenn GM, Dubovsky F, Madhi SA; 2019nCoV-501 Study Group. Efficacy of NVX-CoV2373 Covid-19 Vaccine against the B.1.351 Variant. N Engl J Med. 2021 May 5. doi: 10.1056/NEJMoa2103055. Epub ahead of print. PMID: 33951374.

Update 5 May – source 28 added

Source 28 – 10 vaccinated & lactating women from Singapore

This MedRxiv preprint reports ten women who had received the Biontech BNT162b2 vaccine while lactating (click here or source). Citation: Jia Ming Low, Yue Gu, Melissa Shu Feng Ng, Zubair Amin, Le Ye Lee, Yvonne Peng Mei Ng, Bhuvaneshwari D/O Shunmuganathan, Yuxi Niu, Rashi Gupta, Paul Anantharajah Tambyah, Paul A MacAry, Liang Wei Wang, Youjia Zhong BNT162b2 vaccination induces SARS-CoV-2 specific antibody secretion into human milk with minimal transfer of vaccine mRNA medRxiv 2021.04.27.21256151; doi: https://doi.org/10.1101/2021.04.27.21256151

Update 2 May – source 27 added

Source 27 – no pregnancies among 21 women with thrombotic thrombocytopenia after Oxford/AZ or Janssen/J&J vaccines

Of 11 cases (including nine women age 22-49) of thrombotic thrombocytopenia after the Oxford/Astra Zeneca ChAdOx1 nCov-19 vaccine, none were currently or recently pregnant (click here or source). Citation: Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med. 2021 Apr 9. doi: 10.1056/NEJMoa2104840. Epub ahead of print. PMID: 33835769. Of 12 cases (all women under age 60) following the Janssen/Johnson & Johnson Ad26.COV2.S vaccine, none were currently or recently pregnant (click here or source). Citation: See I, Su JR, Lale A, et al. US Case Reports of Cerebral Venous Sinus Thrombosis With Thrombocytopenia After Ad26.COV2.S Vaccination, March 2 to April 21, 2021. JAMA. Published online April 30, 2021. doi:10.1001/jama.2021.7517

Update 22 April – source 26 added

Source 26 – 35,691 vaccinated pregnant people from USA

The first peer reviewed publication with pregnancy outcome data from the v-safe and VAERS vaccine surveillance systems (click here or source). Citation: Tom T. Shimabukuro, Shin Y. Kim, Tanya R. Myers, Pedro L. Moro, Titilope Oduyebo, Lakshmi Panagiotakopoulos, Paige L. Marquez, Christine K. Olson, Ruiling Liu, Karen T. Chang, Sascha R. Ellington, Veronica K. Burkel, Ashley N. Smoots, Caitlin J. Green, Charles Licata, Bicheng C. Zhang, Meghna limchandani, Adamma Mba-Jonas, Stacey W. Martin, Julianne M. Gee, Dana M. Meaney-Delman, for the CDC v-safe COVID-19 Pregnancy Registry Team. Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons. New Engl J Med April 21, 2021 DOI: 10.1056/NEJMoa2104983

Update 18 April – source 25 added

Source 25 – 131 reproductive-age vaccine recipients from USA

Further immunological studies from the same 84 pregnant, 31 lactating, and 16 non-pregnant women who received either the Pfizer/BioNTech or Moderna mRNA vaccines reported in source 15 (click here or source). Citation: Atyeo C, DeRiso EA, Davis C, Bordt EA, DeGuzman RM, Shook LL, Yonker LM, Fasano A, Akinwunmi B, Lauffenburger DA, Elovitz MA, Gray KJ, Edlow AG, Alter G. COVID-19 mRNA vaccines drive differential Fc-functional profiles in pregnant, lactating, and non-pregnant women. bioRxiv [Preprint]. 2021 Apr 5:2021.04.04.438404. doi: 10.1101/2021.04.04.438404. PMID: 33851165; PMCID: PMC8043455.

Update 16 April – source 24 added

Source 24 – 1,508 vaccinated pregnant women from Israel

There were 1,508 vaccinated pregnant women in this real world study of 596,618 people who received the BNT162b2 mRNA vaccine between December 20, 2020, and to February 1, 2021, and an equal number of matched unvaccinated controls (click here or study). Data from Clalit Health Services, insurer of about half the Israeli population. Citation: Dagan N, Barda N, Kepten E, Miron O, Perchik S, Katz MA, Hernán MA, Lipsitch M, Reis B, Balicer RD. BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Mass Vaccination Setting. N Engl J Med. 2021 Apr 15;384(15):1412-1423. doi: 10.1056/NEJMoa2101765. Epub 2021 Feb 24. PMID: 33626250; PMCID: PMC7944975.

Update 15 April – sources 22 and 23 added

Source 23 – Follicular function in nine vaccinated women from Israel

The authors of this MedRxiv preprint report follicular function in nine women vaccinated with the BNT162b2 mRNA vaccine (click here or source). They were cared for at Hadassah-Hebrew University Medical Center, in Jerusalem. Citation: Yaakov Bentov, Ofer Beharier, Arbel Moav-Zafrir, Maor Kabessa, Miri Godin, Caryn S. Greenfield, Mali Ketzinel-Gilad, Efrat Esh Broder, Hananel E. G. Holzer, Dana Wolf, Esther Oiknine-Djian, Iyad Barghouti, Debra Goldman-Wohl, Simcha Yagel, Asnat Walfisch, Anat Hersko Klement Ovarian follicular function is not altered by SARS-Cov-2 infection or BNT162b2 mRNA Covid-19 vaccination. medRxiv 2021.04.09.21255195; doi: https://doi.org/10.1101/2021.04.09.21255195

Source 22 – Twenty two vaccinated & breast-feeding women from USA

The authors of this MedRxiv preprint report SARS-CoV-2 IgA and IgG levels in the milk of 22 lactating women who had received the SARS-CoV-2 mRNA vaccine (Pfizer/BioNtech or Moderna) (click here or source). They were cared for at Shands Hospital, in Florida. Citation: Vivian Valcarce, Lauren S. Stafford, Josef Neu, Nicole Cacho, Leslie Parker, Martina Mueller, David J Burchfield, Nan Li, Joseph Larkin III Detection of SARS-CoV-2 specific IgA in the human milk of COVID-19 vaccinated, lactating health care workers medRxiv 2021.04.02.21254642; doi: https://doi.org/10.1101/2021.04.02.21254642

Update 14 April – source 15 updated

Update 13 April – source 22 added

Source 22 – 84 vaccinated breast feeding women from Israel

Women who had received 2 doses of the Pfizer-BioNTech vaccine and were breastfeeding (click here or source). There were no serious adverse events, and antibodies were detected in breast milk. Citation: Perl SH, Uzan-Yulzari A, Klainer H, et al. SARS-CoV-2–Specific Antibodies in Breast Milk After COVID-19 Vaccination of Breastfeeding Women. JAMA. Published online April 12, 2021. doi:10.1001/jama.2021.5782

Update 7 April – source 7 update.

Update 6 April– source 21 added

Source 21 – 69,337 women in v-safe were pregnant. 3,953 in v-safe vaccine register

As of March 29th, 69,337 v-safe participants indicated they were pregnant at the time they received COVID-19 vaccination. 3,953 women have also been enrolled in the v-safe COVID-19 Vaccine Pregnancy Registry. Click here for details. The data up to February 16 (published 1 March) (click here or source) includes 30,494 pregnancies (16,039 Pfizer/Biontech and 14,455 Moderna). Adverse events include 29 miscarriages and one stillbirth.

Update 2 April source 20 added

Source 20 – 27 vaccinated women from USA

Twenty seven vaccinated women who delivered at Prentice Women’s Hospital in Chicago, (January-March 2021) (click here or source). 25/28 (one set of twins) infants had positive cord IgG. The exact vaccine is not reported but the authors note that at the time Pfizer/BioNTech and Moderna/NIH were available. Citation: MITHAL LB, OTERO S, SHANES ED, GOLDSTEIN JA, MILLER ES, Cord Blood Antibodies following Maternal COVID-19 Vaccination During Pregnancy, American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2021.03.035.

Update 17 March – source 19 added

Source 19 – 20 vaccinated women from Israel

This MedRxiv preprint reports 20 pregnant women who received two doses of the Pfizer/BioNTech vaccine in late pregnancy in February 2021 (click here or 2021.03.11.21253352v1.full). All women efficiently transferred antibodies to the fetus. They were cared for at Hadassah Medical Center in Jerusalem. Citation: Amihai Rottenstreich, Gila Zarbiv, Esther Oiknine-Djian, Roy Zigron, Dana G. Wolf, Shay Porat. Efficient maternofetal transplacental transfer of anti- SARS-CoV-2 spike antibodies after antenatal SARS-CoV-2 BNT162b2 mRNA vaccination medRxiv 2021.03.11.21253352; doi: https://doi.org/10.1101/2021.03.11.21253352

Update 10 March – sources 15 to 18 added

Source 18 – 6 postnatal vaccinated women in USA

The MedRxiv preprint describes six lactating women who received both doses of the Pfizer-BioNTech or Moderna vaccine between December 2020 and January 2021 (click here or 2021.02.23.21252328v1.full). They all developed IgA and IgG antibodies in breast milk within seven says. They were cared for at Providence Portland Medical Center, Oregon. Citation: Jill K. Baird, Shawn M. Jensen, Walter J. Urba, Bernard A. Fox, Jason R. Baird SARS-CoV-2 antibodies detected in human breast milk post-vaccination. medRxiv 2021.02.23.21252328; doi: https://doi.org/10.1101/2021.02.23.21252328

Source 17 – case report of 3rd trimester vaccination from USA

A 34-year-old woman received the Pfizer-BioNTech, mRNA vaccine at 32 weeks (click here or 13224_2021_Article_1436). The birth was uncomplicated and the baby had cord blood antibodies. The hospital is unnamed, but the authors were from University of Minnesota, Minneapolis. This is the first peer reviewed report of vaccination in pregnancy. Citation: Gill L, Jones CW. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Antibodies in Neonatal Cord Blood After Vaccination in Pregnancy. Obstet Gynecol. 2021 Mar 8. doi: 10.1097/AOG.0000000000004367. Epub ahead of print. PMID: 33684922.

Source 16 – 10 nursing mothers vaccinated in Israel

This MedRxiv preprint describes ten nursing mothers who received the Pfizer-BioNTech mRNA vaccine (click here or 2021.03.06.21252603v1.full). Clinical details and exact vaccine timings in supplementary table 1 (click here or media-1) From author affiliations the women were probably cared for at Lis Maternity & Women’s Hospital, Tel Aviv. Citation: Michal Rosenberg Friedman, Aya Kigel, Yael Bahar, Yariv Yogev, Yael Dror, Ronit lubetzky, Ariel Many, Yariv Wine BNT162b2 COVID-19 mRNA vaccine elicits a rapid and synchronized antibody response in blood and milk of breastfeeding women medRxiv 2021.03.06.21252603; doi: https://doi.org/10.1101/2021.03.06.21252603

Source 15 – 131 reproductive-age vaccine recipients from USA

This MedRxiv preprint includes 84 pregnant, 31 lactating, and 16 non-pregnant women who received either the Pfizer/BioNTech or Moderna mRNA vaccines (click here or 2021.03.07.21253094v1.full). From author affiliations the hospitals were probably Massachusetts General Hospital, and Brigham and Women’s Hospital, both in Boston, Massachussetts. Citation: Kathryn J Gray, Evan A Bordt, Caroline Atyeo, Elizabeth Deriso, Babatunde Akinwunmi, Nicola Young, Aranxta Medina Baez, Lydia L Shook, Dana Cvrk, Kaitlyn James, Rose De Guzman, Sara Brigida, Khady Diouf, Ilona Goldfarb, Lisa M Bebell, Lael M Yonker, Alessio Fasano, Sayed A Rabi, Michal A Elovitz, Galit Alter, Andrea G Edlow COVID-19 vaccine response in pregnant and lactating women: a cohort study medRxiv 2021.03.07.21253094; doi: https://doi.org/10.1101/2021.03.07.21253094 Update 14 March. For peer reviewed publication (click here or source). Citation: Gray KJ, Bordt EA, Atyeo C, Deriso E, Akinwunmi B, Young N, Medina Baez A, Shook LL, Cvrk D, James K, De Guzman R, Brigida S, Diouf K, Goldfarb I, Bebell LM, Yonker LM, Fasano A, Rabi SA, Elovitz MA, Alter G, Edlow AG, COVID-19 vaccine response in pregnant and lactating women: a cohort study, American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2021.03.023.

Update 6 March – sources 13 and 14 added. (We do not plan to update these unless the links change).

Source 14 – UK Yellow card reports for COVID-19 vaccine AstraZeneca

Available here. The latest (25 Feb) report (click here or COVID-19_AstraZeneca_Vaccine_Analysis_Print) included 1 vaccine exposure before pregnancy, 30 during pregnancy and 9 postnatal (p 23). The adverse events included 4 spontaneous abortions, 1 or 2 preterm births, and ten cases of morning sickness (p 41). This was out of 42,917 reports, of 157,637 reactions, of which 244 were fatal. Readers should note that “Conclusions on the safety and risks of the vaccines cannot be made on the data shown in the Print alone” and “The overall safety experience with both vaccines is so far as expected from the clinical trials.”  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/966183/COVID-19_AstraZeneca_Vaccine_Analysis_Print.pdf Accessed 6 March (Not updated unless links change)

Source 13 – UK Yellow Card reports for COVID-19 mRNA Pfizer- BioNTech vaccine

Available here. The latest (4th March) report (click here or COVID-19_mRNA_Pfizer-_BioNTech_Vaccine_Analysis_Print__2_) included 1 vaccine exposure before pregnancy, 37 during pregnancy and 9 postnatal (p 24). The adverse events included 16 spontaneous abortions, 2 or 3 preterm births, and four cases of morning sickness (p 42). This was out of 29,715 reports, of 85,179 reactions, of which 212 were fatal. Readers should note that “Conclusions on the safety and risks of the vaccines cannot be made on the data shown in the Print alone” and “The overall safety experience with both vaccines is so far as expected from the clinical trials.” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/966631/COVID-19_mRNA_Pfizer-_BioNTech_Vaccine_Analysis_Print__2_.pdf Accessed 6 March. (Not updated unless links change)

Update 28 Feb – sources 11 and 12 added

Source 12 – Janssen register trial of Ad26.COV2.S in pregnancy

Janssen have registered an RCT of the vaccine Ad26.COV2.S in pregnant women (click here). Planned sample size 824. Anticipated primary completion date January 16, 2023

Source 11 – Pfizer/BioNTech register trial of BNT162b2 in pregnancy

Pfizer/BioNTech have registered an RCT of the vaccine BNT162b2 in pregnant women (click here). Planned sample size 4,000. Estimated primary completion date January 8, 2023

Update 24 Feb – source 10 added

Source 10 – Janssen Ad26.COV2.S Vaccine FDA briefing document

See p 52 for pregnancy data (click here or VRBPAC-02.26.21-Meeting-Briefing-Document-FDA). “Eight pregnancies were reported through January 22, 2021 (4 vaccine, 4 placebo). In 7 participants (3 vaccine, 4 placebo) vaccination was within 30 days after LMP, and in 1 vaccine recipient vaccination was prior to LMP. Unsolicited AEs related to pregnancy include spontaneous abortion (1 vaccine, 0 placebo), incomplete abortion (0 vaccine, 1 placebo), elective abortion (0 vaccine, 2 placebo) and ectopic pregnancy (1 vaccine, 0 placebo). Among participants in the vaccine group, two pregnancies are ongoing with outcomes unknown at this time.” Note: Janssen is a subsidiary of Johnson & Johnson, and the Ad26.COV2.S vaccine is usually referred to in the press as the “Johnson & Johnson vaccine”. Citation: Vaccines and Related Biological Products Advisory Committee Meeting. February 26, 2021. FDA Briefing Document. Janssen Ad26.COV2.S Vaccine for the Prevention of COVID-19. Accessed 24 Feb 2021 https://www.fda.gov/media/146217/download

Update 21 Feb – Source 9 added – special HT Keelin O’Donogue. One out of 31,000 vaccinations!

Source 9 – one pregnant woman tested positive following vaccination

This preprint reports 31,069 people who received at least one dose of a COVID-19 vaccine via the Mayo Clinic health system, in Arizona, Florida, Minnesota, or Wisconsin, between December 1st 2020 and February 8th 2021. Of the 263 who subsequently received a positive PCR test, one (0.4%) was pregnant (table 3) (click here or Pawlowski pre print). In a propensity matched cohort of 2,630 unvaccinated individuals who also tested positive, seven (0.3%) were pregnant. Citation: Colin Pawlowski, Patrick Lenehan, Arjun Puranik, Vineet Agarwal, AJ Venkatakrishnan, Michiel J.M. Niesen, John C. O’Horo, Andrew D. Badley, John Halamka, Venky Soundararajan. FDA-authorized COVID-19 vaccines are effective per real-world evidence synthesized across a multi-state health system. medRxiv 2021.02.15.21251623; doi: https://doi.org/10.1101/2021.02.15.21251623&nbsp;

Update 20 Feb – Source 8 added

Source 8 – 15,131 post vaccine pregnancies reported to V-safe

Up to 20 January 8,633 pregnancies related to, or following, the Pfizer-BioNTech vaccine and 6,498 after the Moderna vaccine had been self-reported to the CDC using the V-safe vaccine tracker (click here or 06-COVID-Shimabukuro). Over the same period nearly 22m people had received at least one vaccine dose, and 2M had registered with the V-safe vaccine tracker.  As of January 22nd, 227 pregnancies had also been enrolled in the V-safe pregnancy registry. Citation: Advisory Committee on Immunization Practices (ACIP): COVID-19 vaccine Safety update—January 2021 (slide deck)

Update 6 Feb – source 7 added

Source 7 – IgG in cord blood post SARS-CoV-2 vaccine

This Medxiv preprint reports detection of anti-SARS-CoV-2 IgG in a baby whose mother had received the Moderna mRNA COVID-19 vaccine three weeks prior to birth (click here or 2021.02.03.21250579v1.full). The baby was healthy, with normal newborn nursery course and subsequent well-infant evaluation. The hospital is unnamed but the authors were affiliated with Charles E. Schmidt College of Medicine, Boca Raton, Florida. Citation: Paul D Gilbert, Chad A Rudnick. Newborn antibodies to SARS-CoV-2 detected in cord blood after maternal vaccination. medRxiv 2021.02.03.21250579; doi: https://doi.org/10.1101/2021.02.03.21250579 Update 7 April. Peer reviewed paper published in BMC Pediatrics (click here or source). Citation: Paul G, Chad R. Newborn antibodies to SARS-CoV-2 detected in cord blood after maternal vaccination – a case report. BMC Pediatr. 2021 Mar 22;21(1):138. doi: 10.1186/s12887-021-02618-y. PMID: 33752624; PMCID: PMC7982334.

Update 25 Jan – source 6 added

Source 6 – Astra Zeneca/Oxford. Safety & Efficacy report, Lancet

The supplementary appendix of the interim safety and efficacy report of four trials of the Astra Zeneca/Oxford (ChAdOx1 nCoV-19) vaccine reports one spontaneous abortion in the intervention group and one in the control group. For main paper (click here or PIIS0140673620326611) appendix (here or mmc1). These cases are presumably included in Source 3. Citation: Voysey M, Clemens SAC, Madhi SA, Weckx LY, Folegatti PM, Aley PK, Angus B, Baillie VL, Barnabas SL, Bhorat QE, Bibi S, Briner C, Cicconi P, Collins AM, Colin-Jones R, Cutland CL, Darton TC, Dheda K, Duncan CJA, Emary KRW, Ewer KJ, Fairlie L, Faust SN, Feng S, Ferreira DM, Finn A, Goodman AL, Green CM, Green CA, Heath PT, Hill C, Hill H, Hirsch I, Hodgson SHC, Izu A, Jackson S, Jenkin D, Joe CCD, Kerridge S, Koen A, Kwatra G, Lazarus R, Lawrie AM, Lelliott A, Libri V, Lillie PJ, Mallory R, Mendes AVA, Milan EP, Minassian AM, McGregor A, Morrison H, Mujadidi YF, Nana A, O’Reilly PJ, Padayachee SD, Pittella A, Plested E, Pollock KM, Ramasamy MN, Rhead S, Schwarzbold AV, Singh N, Smith A, Song R, Snape MD, Sprinz E, Sutherland RK, Tarrant R, Thomson EC, Török ME, Toshner M, Turner DPJ, Vekemans J, Villafana TL, Watson MEE, Williams CJ, Douglas AD, Hill AVS, Lambe T, Gilbert SC, Pollard AJ; Oxford COVID Vaccine Trial Group. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet. 2021 Jan 9;397(10269):99-111. doi: 10.1016/S0140-6736(20)32661-1. Epub 2020 Dec 8. Erratum in: Lancet. 2021 Jan 9;397(10269):98. PMID: 33306989; PMCID: PMC7723445.

Update 18 Jan – source 5 added

Source 5 – BioNTech/Pfizer. Safety and Efficacy report, NEJM

The Safety and Efficacy report of the phase 2/3 placebo controlled trial of the BioNTech/Pfizer (BNT162b2 mRNA) Covid-19 Vaccine (click here or nejmoa2034577) includes four pregnancies in the vaccine group and five in controls. These will overlap with those in studies 1 and 4Citation; Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW Jr, Hammitt LL, Türeci Ö, Nell H, Schaefer A, Ünal S, Tresnan DB, Mather S, Dormitzer PR, Şahin U, Jansen KU, Gruber WC; C4591001 Clinical Trial Group. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020 Dec 31;383(27):2603-2615. doi: 10.1056/NEJMoa2034577. Epub 2020 Dec 10. PMID: 33301246; PMCID: PMC7745181.

Update 15 Jan – source 4 added

Source 4 – Comirnarty. EMA asessment report

See p 109 for pregnancy data (click here or comirnaty-epar-public-assessment-report_en). Comirnarty is the EU name for the BioNTech/Pfizer vaccine. The data therefore likely overlap with Source 1. Citation: European Medicines Agency. 21 December 2020. EMA/707383/2020. Committee for Medicinal Products for Human Use (CHMP). Assessment report. Comirnaty. Common name: COVID-19 mRNA vaccine (nucleoside-modified) Procedure No. EMEA/H/C/005735/0000. Accessed 14 January 2021. https://www.ema.europa.eu/en/documents/assessment-report/comirnaty-epar-public-assessment-report_en.pdf&nbsp;

Update 14 Jan – Sources 1-3 added

Source 3 – Astra Zeneca/Oxford. MHRA public assessment report

See p 48 onward for pregnancy data (click here or UKPAR_COVID_19_Vaccine_AstraZeneca_05.01.2021). Citation: Medicines and Healthcare products Regulatory Agency. Public Assessment Report. Authorisation for Temporary Supply. COVID-19 Vaccine AstraZeneca, solution for injection in multidose container COVID-19 Vaccine (ChAdOx1-S [recombinant]). Department of Health and Social Care (DHSC) AstraZeneca AB. Accessed January 14 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/949772/UKPAR_COVID_19_Vaccine_AstraZeneca_05.01.2021.pdf&nbsp;

Source 2 – Moderna. FDA briefing document

See p 44 onward for pregnancy data (click here or VRBPAC-12.17.20-Meeting-Briefing-Document-FDA_0). Citation: U.S. Food and Drug Administration. Vaccines and Related
Biological Products Advisory Committee meeting—December 17, 2020—FDA briefing document—Moderna COVID-19 vaccine. Accessed January 14, 2021. https://www.fda.gov/media/144434/download

Source 1 – BioNTech/Pfizer. FDA briefing document

See p 42 onwards for pregnancy data (click here or VRBPAC-12.10.20-Meeting-Briefing-Document-FDA). Citation: U.S. Food and Drug Administration. Vaccines and Related Biological Products Advisory Committee Meeting, December 10, 2020. FDA Briefing Document. Pfizer-BioNTech COVID-19 Vaccine. Accessed January 14 2021. https://www.fda.gov/media/144245/download&nbsp;

Jim Thornton

Cock and balls

December 27, 2020

Mr & Mrs Andrews, and Thomas Gainsborough’s sexual innuendo

Although they had commissioned it, the Andrews’s disliked this painting so much that they never let Gainsborough finish it, and hid it away for nearly 200 years. Now in the National Gallery, it is recognised as the unquestioned masterpiece of Thomas Gainsborough’s early years.  

Part of its fame comes from its mention in “Civilisation”, Kenneth Clark’s book and BBC series, and later in “Ways of Seeing”, John Berger’s critique of Clark (click here). Clark, and the general public, loved the romantic landscape. Berger argued that the painting was an arrogant statement of wealth and privilege. Both were correct.

Thomas Gainsborough was living hand to mouth when he painted it – his father, John Gainsborough, had gone bankrupt – and he found it hard to remain deferential. This couple from his home of Sudbury – Thomas had been to school with Robert Andrews – were inheritors of “new money”. The marriage linked the fortunes of Mr Andrews’ father, also Robert, with that of his neighbour William Carter. Carter and the older Mr Andrews owned equal shares in Auberies, the estate pictured in the painting. Frances, the future Mrs Andrews, was Carter’s daughter, and her mother, Carter’s wife, the daughter of John Gainsborough’s principle creditor. Thomas was commissioned to celebrate the marriage and inheritance. 

Gainsborough considered himself primarily a landscape painter, and although the composition, with the figures off-centre, revealing so much landscape, was unusual for this sort of dynastic art – one reason it is so popular today – it is unlikely that this caused the ruction. Robert was surely happy to show off his modern farming techniques. Gainsborough also catches Frances’ disdainful expression, perhaps the lowly painter was rather over familiar, but there was a bigger reason for the falling out. Look closely at Robert’s waist1

At Robert’s belt, a bag for his shot and powder hangs – the shot in the left section, the powder in the tube with the knot in it on the right. This is what Robert’s muzzle loading flintlock needs to fire. Now whatever does the bag look like? Yes, its shape unmistakeably echoes male genitalia, while its form and proximity to the gun demonstrates explosive purpose. It is placed decidedly beside the crotch, so we may be being led to understand that Robert is remarkably well hung. However, on the left, above the tower of what is possibly Long Melford Church, dark clouds are gathering, and in the enclosure below, more or less where a swimming pool is now, and set on the same horizontal line as Robert’s significant powder-and-shot bag, are a pair of trapped donkeys. Did Gainsborough see his patrons as trapped donkeys?

Or the unfinished space on Frances’s lap. Was it intended to add a baby, a pet dog, or what?

The empty space is more or less egg shaped […] in her right hand an apparently meaningless furry or feathery extension, nearly as long as her lower arm, emerges from the partially expressed object on her lap. The drily painted beginnings of a small oval, merely a swish or two of the brush, runs over thin grey under-drawing which extends down to a dangling knob-shape. It is unquestionably there, in plain sight. This is not a pet cat, or a lap-dog, or a baby, but a dead cock pheasant – or it was going to be. Had Gainsborough completed it, the pheasant’s head and neck would rhyme exactly, and rather too clearly, with the limp game bag at Robert’s waist and the flabby glove in his hand. As it is, as Gainsborough has left it, Frances Andrews has a drawing of a penis on her skirt.

We can only guess what Frances said when she saw the painting. But we know the result. 

Jim Thornton

  1. None of this was worked out by me. Most of the facts, and both quotations, are from Gainsborough, a Portrait by James Hamilton. Weidenfeld & Nicholson, London, 2017.

Birth carers lost to Covid-19

December 13, 2020

Looking after mothers and babies during childbirth never stops – nights, weekends, holidays, the lights in the labour and neonatal wards are always on – and it didn’t stop for Covid.  Midwives, obstetric and neonatal nurses, neonatologists, anaesthetists, sonographers, cleaners, porters, auxiliaries, doulas, obstetricians, and many others, carried on as usual. A few paid with their lives.

Some caught Covid-19 in the line of duty, some elsewhere; I’ve made no attempt to separate them. Listed by month of death. Email Jim Thornton for those missed. Thank you Shakila Thangaratinam and Tara Pauly for initial encouragement and for alerting me to some names. 

There seem to be more OBGYN’s than midwives, which is implausible. The explanation is probably that some countries don’t use the term midwife, and that the internet is biased towards recording deaths of doctors before other health professions. 

Some resources used – Venezuela (click here), Italy (click here), Russia (click here), UK/BMJ (click here), US physicians (click here), Iran (click here), Medscape (click here), New York State Nurses Association (click here), Lancet (click here).

I will update.

March 2021 – Jim Dornan added

March 2021 

Jim Dornan age 73, OBGYN, Belfast, Northern Ireland. Death announced on 15 March (click here).  

January 11 update – Jose Jimenez, Gregory Michael, Unnamed midwife from Whittingdon, Adaín Landeros, Tomás Hernández Quijano, Jaime Hernández Rodríguez, Georgi Hubchev, José Alfredo Jiménez Turrubiates, Duško Kljakić, Halil Yucel Kutun, Katia Kohler, Mark Laser, and Biljana Natic ​​Ljumovic added. Details below.

January 2021

An unnamed midwife “originally from Zimbabwe” is reported to have died from Covid-19 at the Whittingdon Hospital in London in early January (click here).

Gregory Michael, age 56, OBGYN, Miami Beach, Florida on 3 January (click here). Cause thrombocytopaenia, two weeks after receiving the BioNTech/Pfizer Covid vaccine. The relation between the two events is under investigation.

December

 

November

Joel Antonio Contreras Gámez, age 87, OBGYN, Táchira, Venezuela, on 24 November (click here).

Liliana Somogy, OBGYN, Carabobo, Venezuela, on 19 November (click here). 

Pierantonio Meroni, age 83, OBGYN from Como, Italy, on 17 November (click here or here).

Héctor Enrique Torrealba Rodríguez, age 68, OBGYN, Carabobo, Venezuela, on 12 November (click here).

Adaín Octavio Girón Landeros, age 42, OBGYN, Hospital General de Zacatecas, Zacatecas, Mexico, on 12 November (click here).

October

Carlos Fayanás, age 73, OBGYN, Juncal Sanatorium in Temperley, Lomas de Zamora, Argentina, on 22 October (click here). 

Georgi Hubchev, age 66, OBGYN, University Hospital “Virgin Mary” Burgas, Bulgaria, on 17 October (click here).

Jose Inés Alcántara Jimenez, age about 64, OBGYN, Hospital General Iguala, Iguala, Guerrero, Mexico on 12 Octobe (click here).

Rafael Colmenares, OBGYN, Trujillo, Venezuela, on 1st October (click here).

Nikolay Vasechko, age 59, a doctor in diagnostic ultrasound in Dobrinsky Regional Hospital, Lipetsk, Russia, in October (click here). 

Jagadish Rai, age 70, OBGYN, Raju Clinic, BC Road, Bantwal, India, in October (click here). 

September 

Tatyana Babaytseva, age 53, ultrasound doctor, Uryupinsk District Hospital, Volgograd, Russia, in September (click here).

Pedro Sánchez, age 65, Distrito Capital, Venezuela, on 21 September (click here).

Freddy Lacroix, OBGYN, Carabobo, Venezuela, on 20 September (click here).

Adeline Fagan, age 28, trainee OBGYN, Houston, Texas, on 19 September (click here).

Ana Mercedes Flores, OBGYN, Maternidad del Sur, Carabobo, Venezuela, on 13 September (click here).

Elio José Margiotta Figueroa, age 60, OBGYN, Nueva Esparta, Venezuela, on 7 September (click here).

Manuela Fernández Lanz, age 60, OBGYN, Bolívar, Venezuela, on 3 September (click here).

August

Pedro Luis Cedeño, age 56, OBGYN, on 30 August (click here).

Andrés del Orbe, OBGYN, Táchira, Venezuela on 30 August (click here).

Julia Morales, OBGYN, Trujillo, Venezuela, on 28 August (click here).

Franklin Urdaneta, OBGYN, Zulia, Venzuela, on 24 August (click here). 

Junny Macabril, OBGYN, Bolivar, Venezuela, on 24 August (click here).

Kathlynne Abat-Senen, age 43, neonatologist from Manila, Philippines, On 23 August (click here). 

Dalia Gabriela Sosa Atondo, age 28, OBGYN, Culiacán, Mexico, on 21 August (click here or here). She was pregnant. Her baby survived. 

Jesús García, OB/GYN, Hospital Materno Infantil “Dr Pastor Oropeza,” Caracas, Venezuela on 20 August (click here). 

Carlos Alberto Amaya, neonatologist, Hospital de Niños Benjamín Bloom, San Salvador, El Salvador on 18 August (click here).

Ángel Ruben Alzurutt Riera, OBGYN, from Ciudad Guayana, Venezuela on 17 August (click here). 

Yamil Abou Assali, age 60, OBGYN, Barinas, Venezuela, on 8 August (click here).

Felipe De La Cruz Luna, OBGYN, Apartadó, Colombia on 5 August (click here). 

Halil Yucel Kutun, age 67, OBGYN, Ozel Bag Hospital, Diyarbakir, Turkey, on 4 August (click here).

Jesús Peña Peña, age 67, OBGYN, Hospital de Santa Bárbara, Mérida, Venezuela on 4 August (click here). 

July 

Alcira Perache, age 52, OBGYN, Hospital Dr Raúl Leoni, Ciudad Guayana, Bolívar, Venezuela, on 31 July (click here).  

Germán Mauricio Erazo Santos, OBGYN, Hospital Gabriela Alvarado, Danlí, Honduras on 29 July (click here). 

Óscar Urenda, age 72, OBGYN, Santa Cruz, La Paz, Bolivia, On July 23 (click here).

Ana Henríquez Salazar, age 52, OBGYN, Distrito Capital, Venezuela, on 22 July (click here).

María Consuelo González, OBGYN, Distrito Capital, Venezuela, on 13 July (click here).

Doreen Lugaliki, age 39, OBGYN in Kenya on 10 July (click here). 

Jesús Romero, age 54, OBGYN,  Rosario de Perijá, Zulia, Venezuela. on 10 July (click here).

Elias José Hani Jimeno, age 64, OBGYN, Clínica Misericordia, Ciénaga, Magdalena, Colombia in July (click here).

Matilde Ramírez García,  OB-GYN, Hospital Regional de Coatzacoalcos “Dr. Valentin Gomez Farias,” Coatzacoalcos, Veracruz, Mexico, on 3rd July (click here). 

José Alfredo Jiménez Turrubiates, OBGYN, Hospital General Matamoros “Dr. Alfredo Pumarejo,” Matamoros, Tamaluipas, Mexico, on 2 July (click here)

Nola Mae Moore, age 98, family practitioner, King County, Washington, USA, who had delivered almost 5,000 babies in partnership with her husband, in June (click here). 

June

Jorge Leal, age 56, OBGYN, Zulia, Venezuela, on 28 June (click here).

Manuel Romero, age 54, OBGYN, Maracaibo, Zulia, Venezuela, on 24 June (click here). 

Sergio de la Fuente Burton, age 73, OBGYN, American Hospital, Cancun, Mexico, on 2nd June (click here).

May 

Ramon César Aparicio Osorio, OBGYN, director of Hospital Materno Infantil Vicente Guerrero, Chimalhuacán, Mexico in May (click here).

Carla de Oliveira Obelar, age 42, neonatal nurse, Rio de Janeiro, Brazil, in May (click here).

Ahmed Al-Annie, OBGYN, from Banha Insurance Hospital, Banha, Egypt in May (click here).

Eder Aguilar Rojas, OBGYN from Iquitos, Peru in May (click here).

Nicolás Hernández Hernández, OBGYN from Iquitos, Peru in May (click here).

Margaret Njenga, midwife, Barts Health NHS Trust, London, UK, in May (click here). 

Safaa Alam, age 30, midwife, Birmingham, UK in May (click here or here).

Jaime Hernández Rodríguez, OBGYN, General Hospital of Zona 13 de Matamoros.Tamaluipas, Mexico  (click here).

Esperanza Bravo Ruíz, neonatologist, Puebla, Mexico, on May 13 (click here). 

Daniel Mojica, administrator, Hospital de Gineco Obstetricia No. 3 de La Raza, Mexico City, Mexico on 9 May (click here).

Duško Kljakić, age 52, OB-GYN,  General Hospital “Blažo Orlandic,” Bar, Montenegro, on 9 May (click here).

Veselago Larisa Mikhailovna, age 71, OBGYN, St. Petersburg, Russia on 8 May (click here).

Claudio Antonio Figueiredo Reis, age 63, OBGYN, Hospital Anita Gerosa, Ananindeua, Brazil on 6 May (click here).

Svetlana Vinokur, age 56, obstetric nurse, NYC Health+Hospitals/Coney Island, Brooklyn, New York, on 1 May (click here).

April 

Reinaldo Albernás, age 54, OBGYN, in Hospital San Rafael de Alajuela, Alajuela, Costa Rica, in April (click here).

Khanyafi Garifullin, age 61, OBGYN from Dzerzhinsk City hospital, Moscow, Russia, on 30 April (click here).

Avelar Feitosa Ribeiro, OBGYN, Hospital Divina Providência, Marituba, Pará, Brazil, on 27 April (click here). 

Azinet Pudpud, age 61, neonatal nurse, Lincoln Hospital, New York, on 27 April (click here). 

Elma Cavalida, a maternity assistant at Northwick Park Hospital, on April 26 (click here). 

Gerardo Zenteno Gutiérrez, OBGYN, Clínica de Especialidad Nuestra Señora de Los Ángeles, Puebla, Mexico, on April 25 (click here).

Shree Vishna Rasiah, age 49, neonatologist, Birmingham, UK, on 23 April 2020 (click here or here)

Arthur Tayengco, age 81, OBGYN, University of Nevada-Las Vegas School of Medicine, USA, on 22 April (click here or here).

Alicia Soto Guerrero, age 65, radiologist, Sinaloa, Mexico, previously intern in OBGYN, on 20 April (click here or here).

Tomás Hernández Quijano, OBGYN IMSS Hospital Vicente Guerrero, Acapulco, Mexico between 19 and 23 April (click here).

Joshua Yasuo Suzuki, age 78, OBGYN, Seattle, USA, on April 19 (click here or here).

Linda Clarke, age 66, midwife, Wigan, UK, on 16 April (click here). 

Alberto Guidetti, age 76, OBGYN, Arzignano and Valdagno Hospitals in Creazzo, Italy, on 15 April (click here).

Emeka Chugbo, age 60, OBGYN, Lagos, Nigeria, on 15 April (click here. See also here).

Emma Altagracia Barba Demorizi, Dominican Republic, on 14 April (click here).

Katia Kohler, OBGYN, Santana de Parnaiba, Brazil, on 13 April (click here).

Raimundo Ferreira Rodrigues, age 75, OBGYN, Manaus, Brazil, on 12 April (click here). 

Betty Cruz Yagual, age 61, OBGYN, Santiago de Guayaquil, and El Cisne, Health Centers, in Ecuador, on 10 April (click here). 

Edoardo Valli, age 63, OBGYN at Santa Famiglia obstetric clinic, Rome, on 9 April (click here).

Luis Caldera-Nieves, age 63, OBGYN, from Jackson South Community Hospital in Palmetto Bay, Miami, Florida on 8 April (click here). 

Susan Sisgundo, neonatal nurse, Bellevue Hospital, New York, on April 8 (click here).

Alice Kit Tak Ong, age 70, midwife from North London, UK, on 7 April (click here or here).

Aria Sigaroudi, midwife, Sari, Iran, on 7 April (click here). 

Mark Laser, age 63, OBGYN, Women’s Healthcare, Trumbull, Connecticut, on 7 April (click here).

Luis Caldera-Nieves, age 63, OBGYN, Miami, Florida, on 7 April (click here).

Jack Zoller, OBGYN, New Orleans, Louisiana on 2 April (click here). 

Lynsay Coventry, age 54, midwife, Princess Alexandra Hospital Trust, Harlow, Essex, UK, on 2 April (click here). 

Hamza Pacheeri, age 80, OBGYN, Birmingham, United Kingdom on April 1 (click here). 

March

Ricardo A. Alcivar Zambrano, age 67, Neonatologist, Guayaquil, Ecuador, in March (click here).

Gianfranco D’Ambrosio, OBGYN and GP, Italy, on 30 March (click here).

Irving Buterman, age 78, OBGYN, New York, on March 30 (click here).

Washington Germán Tutasi Jaramillo, age 68, OBGYN, Ambate, Ecuador, on March 28 (click here). 

Carlos Enrique Burbano Freire, age 50, Guayaquil, Ecuador, on 26 March (click here).

Biljana Natic ​​Ljumovic, age 59, OBGYN, Niš, Serbia, on 25 March (click here). 

Liliana Ortega Miranda, age 45, OBGYN, Hospital Nacional Sergio Bernales, Comas, Peru, on 23 March (click here). 

Jean-Marie Boegle, age 66, OBGYN, Mulhouse, France, on 22 March (click here or here).

Valter Tarantini, age 72, OBGYN, Forlì, Italy, on 19 March (click here or here).

Roberto Mileti, age 59, OBGYN, San Marco, Italy, on 30 March (click here).

Month unknown

Bugornikova Galina Valentinovna, age 59, OBGYN, Ust-Pristanskiy, Altai Territory, Russia (click here).

Anusheh Beikian, OBGYN, Rasht, Iran (click here).

Seyyedeh Azemat Mousavi, OBGYN, Sari, Iran (click here). 

Dr. Ali İhsan BULUT, OBGYN, Istanbul (click here)

Ibtihal Hammoud, OBGYN, Aden, Yemen (click here)

Walid Yahya Abdelhaleem, age 32, OBGYN, Almuneerah General Hospital, Cairo, Egypt (click here)

Jim Thornton

Note. For ease of searching, and because many countries use the generic term gynaecologist to include obstetrician, I’ve classified obstetricians, gynaecologists and doctors who practice both, all as OBGYNs. Similarly I’ve classified paediatricians who practice neonatology as neonatologists. 

Wild swimming in the Trent gravel pits

November 30, 2020

Sand and gravel has been quarried along the Trent for hundreds of years. The two official swimming lakes, Colwick Park (click here) and the Notts County Sailing Club lake at Hoveringham (click here or here for details) will suit many. But organised wild swimming? Not me.

Some lakes are inaccessible, or too closely guarded by their owners, but a few are perfect for a discreet dip. For swimming spots on the river click here.

Hoveringham

Three lakes run alongside the railway line here. The smaller ones at either end are heavily  fished – no swimming. But the middle and largest, Railway Lake, is perfect. A sailing, canoeing & windsurfing club has put up all sorts of entry barriers, and their groundsman believes the whole lake is “no swimming”, so be discreet.

     

Enter by the path at Thurgaton station, but avoid the main footpath along the railway line. It’s over a mile before you can cross the ditch separating you from the lake.  Instead follow the permissive path signs, through an unlocked gate and along the north shore. The further you go, the more private it gets.

      

The best spots are where the trees give way to grass and reeds.

Lovely clean gravel beds. No weeds. Just me and the dragon flies.

Gunthorpe

The Gunthorpe lakes are all owned by angling clubs, who fish all year, and don’t like swimmers. I swam in Dollar Lake, the largest one adjacent to the river. If you walk in from the river bank on a quiet day, there no fences, and the fishermen tend to drive in from the opposite direction.

Bleasby

Bleasby Lake, at the end of Sycamore Lane, near the sawmill, is the only swimmable lake in Bleasby. There’s usually a few fishermen, but it’s rarely crowded, and they’ve never objected to me swimming. Loads of good access points. Weedy in parts.

Jubilee Ponds would be perfect, and they’re accessible on foot down Borrow Bread Lane, but sadly, “No swimming”.

         

Gibsmere lake is also private fishing only – “No swimming”.  But don’t despair. There’s a couple of good spots on the Trent at Hazleton (click here).

Newark/South Muskham

There are many flooded pits between Newark and South Muskham, mostly around the sugar factory. But they’re all fishing lakes, or inaccessible, or both.

North Muskham

North Muskham Lake Nature Reserve (click here) is “no swimming”.  But walk north (downstream) from The Muskham Ferry pub (click here), past the fenced-off Nature Reserve lake. The second lake is set back behind grassland and invisible from the path, but the third is adjacent to the path with easy access. An idyllic spot.

    

Cromwell

You can swim in the river (click here) but the local gravel pit is still being worked by Tarmac – definitely no swimming!

Jim Thornton

Women’s Work

October 26, 2020

Two poems by UA Fanthorpe

      

Degas painted dozens of “La Repasseuse” Woman Ironing pictures. The one Fanthorpe refers to (right above) is in the Walker Art Gallery in Liverpool. It’s the last in a series of three of this particular pose. The George Bernard Shaw quote is from the play Man & Superman.

Woman Ironing

I thought I knew what was coming when he said,
He wanted to do my likeness at the ironing.
I live in the city, people tell you things. Me looking at him,
It would be, across the ironing board, my hair and my eyes
In a good light, and something a bit off the shoulder

But it wasn’t. He rushed around drawing curtains
Made it hard to iron. O yes, I had to keep ironing.
He need to see the strength, he said. Kept on
About my dynamic right shoulder, then left it out
Though you can see where he ought to have put it.

Come on, what’s-your-name, he kept saying,
Show us that muscle power! That’s what I’m after.
I might’ve been an engine, not a person
No, I didn’t take to him, I’m used to rudeness,
But he was making such a sketch of me.

If someone’s paying you, it isn’t easy
To speak your mind. Still, Sir, I said,
I really don’t want to see my hair like that,
all scraped back, like a hot person’s hair,
And anyone can tell that under my arms I’m sweating.

Hair? Sweat? That’s how it is when you iron,
Says he. You’re not here to tell me what to do.
I’ll make you permanent, the way you look
When you’re ironing. O yes, he says, I’ll show you
The way you look when no one’s watching.

UA Fanthorpe

Mother Scrubbing the Floor

She had a dancer’s feet, elegant, witty.
We had our father’s, maverick spreaders of dirt.

Dirt from London, dirt from Kent
Mud, dust, grass, droppings, wetness, things,
Dirt barefaced, dirt stinking, dirt invisible.

Whatever it was, she was ready:
The rubber kneeler, clanking galvanised bucket,
The Lifebuoy, the hard hot water.

Let me! we’d say, meaning Hate to see you do this.
Too old. Too resentful. Besides, you’ll blame us
That you had to do it.

She never yielded. We couldn’t do it right,
Lacking her hatred of filth, her fine strong hands.

Don’t want you to do this, she said. Don’t want you to have to.
Just remember this: love isn’t sex.
But the dreary things you do for the people you love.
And ‘Home is the girl’s prison,
The woman’s workhouse.’ Not me; Shaw.

I do remember. I stand where she knelt.

UA Fanthorpe

Indirect effects of the Covid-19 pandemic on pregnancy

October 8, 2020

Primary sources

Ripe-tomato.org has been collecting primary scientific (click here) & newspaper reports (click here) of Covid-19 or SARS-CoV-2 infection in pregnancy since early in the pandemic (click here for our Covid-19 in pregnancy navigation page).

Here we (Jim Thornton, Keelin O’Donoghue and Kate Walker) collect primary scientific reports of the indirect effects of the pandemic on pregnancy.  As usual facts but no comments. For convenience we list papers in roughly reverse order, newest first. We will update regularly.

Update 6 June – paper 75 added

Paper 75 – increased thromboembolism during lockdown in Israel

In 2020 the rate of pregnancy-related thromboembolic events was significantly higher than in 2018 and 2019 at the Mount Scopus and Ein Kerem campuses of Hadassah-Hebrew University Medical Center in jerusalem (click here or paper). Citation: Gabrieli D, Cahen-Peretz A, Shimonovitz T, Marks-Garber K, Amsalem H, Kalish Y, Lavy Y, Walfisch A. Thromboembolic events in pregnant and puerperal women after COVID-19 lockdowns: A retrospective cohort study. Int J Gynaecol Obstet. 2021 Jun 2. doi: 10.1002/ijgo.13777. Epub ahead of print. PMID: 34077561.

Update 3 June – paper 74 added

Paper 74 – Reduced prematurity in France

Preamature births fell in single but not in multiple pregnancies (click here or paper). There was no alteration in stillbirths. Citation: Simon E, Cottenet J, Mariet A-S, Bechraoui-Quantin S, Rozenberg P, Gouyon J-B, Quantin C, Impact of the COVID-19 pandemic on preterm birth and stillbirth: a nationwide, population-based retrospective cohort study, American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2021.05.015.

Update 29 May – paper 73 added

Paper 73 – emergency dept avoidance but no adverse effects in Canada

In Ontario, after an initial reduction, ED presentations for ectopic pregnancy quickly returned to expected levels. In contrast presentations for miscarriage showed sustained reductions but complications and mortality rates did not alter during the pandemic (click here or paper). Citation: Gomez D, Simpson AN, Sue-Chue-Lam C, de Mestral C, Dossa F, Nantais J, Wilton AS, Urbach D, Austin PC, Baxter NN. A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits. CMAJ. 2021 May 25;193(21):E753-E760. doi: 10.1503/cmaj.202821. PMID: 34035055.

Update 27 May – paper 72 added

Paper 72 – the first wave in Ethiopia

Government health facilities in Bench Sheko, Sheka, Keffa, and West Omo zones in southern Ethiopia reported reduced antenatal, family planning and newborn immunization visits, and health facility births, and more teenage pregnancies, abortions, institutional stillbirths and neonatal deaths during March–June 2020 (click here or paper). Citation: Kassie A, Wale A, Yismaw W. Impact of Coronavirus Diseases-2019 (COVID-19) on Utilization and Outcome of Reproductive, Maternal, and Newborn Health Services at Governmental Health Facilities in South West Ethiopia, 2020: Comparative Cross-Sectional Study. Int J Womens Health. 2021 May 19;13:479-488. doi: 10.2147/IJWH.S309096. PMID: 34040456; PMCID: PMC8141395.

Update 17 May – papers 70 and 71 added

Paper 71 – more ruptured ectopic pregnancies in USA

From Newark, Delaware (click here or paper). Citation: Toma, Helen V. MD, MSPH; Bank, Tracy Caroline MD; Hoffman, Matthew K. MD, MPH Care for Women With Ectopic Pregnancies During the Coronavirus Disease 2019 (COVID-19) Pandemic, Obstetrics & Gynecology: May 06, 2021 – Volume Latest Articles – Issue – 10.1097/AOG.0000000000004392 doi: 10.1097/AOG.0000000000004392

Paper 70 – no change in preterm birth or stillbirth during first 6 months of pandemic

From Ontario, Canada (click here or paper). Citation: Simpson AN, Snelgrove JW, Sutradhar R, Everett K, Liu N, Baxter NN. Perinatal Outcomes During the COVID-19 Pandemic in Ontario, Canada. JAMA Netw Open. 2021;4(5):e2110104. doi:10.1001/jamanetworkopen.2021.10104

Update 16 May – paper 69 added

Paper 69 – More Caesareans in Brazil

From Dr. Miguel Riet Corrêa Jr., University Hospital of the Universidade Federal do Rio Grande (HU-FURG), in the state of Rio Grande do Sul (click here or paper). Citation: Manoela de Azevedo Bicho, Mayra Pacheco Fernandes, Luís Paulo Vidaletti, Juliana dos Santos Vaz. Cesarean section prevalence at a baby-friendly hospital in southern Brazil: current context in the face of COVID-19. medRxiv 2021.05.03.21256516; doi: https://doi.org/10.1101/2021.05.03.21256516

Update 15 May – paper 68 added

Paper 68 – fewer very preterm births during lockdown in Vienna

From the Viennese Danube Hospital (click here or study). Citation: Kirchengast S, Hartmann B. Pregnancy Outcome during the First COVID 19 Lockdown in Vienna, Austria. Int J Environ Res Public Health. 2021 Apr 5;18(7):3782. doi: 10.3390/ijerph18073782. PMID: 33916365; PMCID: PMC8038559.

Update 1 May – paper 67 added

Paper 67 – fewer antenatal attendances in Uganda

The authors of this MedRxiv preprint report many changes in maternity care and outcomes during the first wave at Kawempe National Referral Hospital in Kamapala (click here or paper). Citation: Jessica Burt, Joseph Ouma, Alexander Amone, Lorna Aol, Musa Sekikubo, Annettee Nakimuli, Eve Nakabembe, Robert Mboizi, Philippa Musoke, Mary Kyohere, Emily Namara, Asma Khalil, Kirsty Le Doare. Indirect Effects of COVID-19 on Maternal, Neonatal, Child, Sexual and Reproductive Health Services in Kampala, Uganda medRxiv 2021.04.23.21255940; doi: https://doi.org/10.1101/2021.04.23.21255940

Update 21 April – Paper 66 added

Paper 66 – increase in molar pregnancy in Israel

A doubling in the incidence of molar pregnancies at Galilee Medical Center, Nahariya, in January–October, 2020 (click here or paper). Citation: Aiob A, Naskovica K, Sharon A, Bornstein J. A possible association between hydatidiform mole and the COVID-19 pandemic: A retrospective cohort study. Gynecol Oncol. 2021 Mar 5:S0090-8258(21)00192-X. doi: 10.1016/j.ygyno.2021.02.035. Epub ahead of print. PMID: 33712273; PMCID: PMC7934616.

Update 11 April – papers 64 and 65 added

Paper 65 – fewer births and terminations in Italy

From the Institute for Maternal and Child Health, Trieste (click here or paper). Citation: Trombetta A, Travan L, Elefante P, Canton M, Rispoli F, Maso G, Barbi E, Risso FM. The first Italian COVID-19 lockdown reduced births and voluntary terminations by just under a fifth. Acta Paediatr. 2021 Mar 29. doi: 10.1111/apa.15862. Epub ahead of print. PMID: 33780031.

Paper 64 – reduced preterm birth rate in Saudi Arabia

From King Saud Medical City, Riyadh (click here or paper). Citation: Huseynova R, Bin Mahmoud L, Abdelrahim A, Al Hemaid M, Almuhaini MS, Jaganathan PP, Career H, Huseynov O. Prevalence of Preterm Birth Rate During COVID-19 Lockdown in a Tertiary Care Hospital, Riyadh. Cureus. 2021 Mar 1;13(3):e13634. doi: 10.7759/cureus.13634. PMID: 33816033; PMCID: PMC8011548.

Update 30 March – paper 63 added

Paper 63 – national changes in US

This MedRxiv preprint reports a fall in live births, preterm births and low birth weight babies in the United States during the pandemic (click here or paper). Citation: Alison Gemmill, Joan A. Casey, Ralph Catalano, Deborah Karasek, Tim Bruckner. Changes in live births, preterm birth, low birth weight, and cesarean deliveries in the United States during the SARS-CoV-2 pandemic. medRxiv 2021.03.20.21253990; doi: https://doi.org/10.1101/2021.03.20.21253990

Update 21 March – papers 61 and 62 added

Paper 62 – fewer OBGYN emergency hospital visits during first wave

Data from Kaiser Permanente Northern California, Oakland (click here or ). Citation: Abel, Mary Kathryn AB; Alavi, Mubarika X. MS; Tierney, Cassidy MD; Weintraub, Miranda Ritterman PhD, MPH; Avins, Andrew MD, MPH; Zaritsky, Eve MD Coronavirus Disease 2019 (COVID-19) and the Incidence of Obstetric and Gynecologic Emergency Department Visits in an Integrated Health Care System, Obstetrics & Gynecology: March 10, 2021 – Volume Latest Articles – Issue – 10.1097/AOG.0000000000004331 doi: 10.1097/AOG.0000000000004331 

Paper 61 – more abortion referrals and procedures during first wave.

From author affiliations the unnamed Northern California tertiary referral center may have been Dept. OBGYN, University of California, Davis, in Sacramento (click here or PgwZqt-PIIS0002937821001587). Citation: Creinin MD, Tougas H, Wilson M, Matulich MC, COVID-19 impact on abortion care at a Northern California tertiary family planning program American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2021.03.007.&nbsp;

Update 20 March – paper 60 added

Paper 60 – no change in ethnic disparities in preterm birth in New York

Women who delivered from March 28 to July 31, 2020, in New York City, were compared with women who delivered from March 28 to July 31, 2019 (click here or janevic_2021_oi_210084_1615398911.43761). Citation: Janevic T, Glazer KB, Vieira L, Weber E, Stone J, Stern T, Bianco A, Wagner B, Dolan SM, Howell EA. Racial/Ethnic Disparities in Very Preterm Birth and Preterm Birth Before and During the COVID-19 Pandemic. JAMA Netw Open. 2021 Mar 1;4(3):e211816. doi: 10.1001/jamanetworkopen.2021.1816. PMID: 33729505.

Update 3rd March – papers 58 and 59 added. Additional data & citation paper 10. Paper 15 (abstract) and paper 22 (full paper) noted to report the same data.

Paper 59 – no change in preterm births in Massachussetts

Preterm birth rates, defined in various ways, did not alter significantyl in four Boston hospitals during the pandemic, compared with the previous year (click here or Preterm_Birth_During_the_Coronavirus_Disease_2019.2). Citation: Wood, Rachel MD; Sinnott, Colleen MD; Goldfarb, Ilona MD; Clapp, Mark MD, MPH; McElrath, Thomas MD, PhD; Little, Sarah MD, MPH Preterm Birth During the Coronavirus Disease 2019 (COVID-19) Pandemic in a Large Hospital System in the United States, Obstetrics & Gynecology: March 2021 – Volume 137 – Issue 3 – p 403-404. doi: 10.1097/AOG.0000000000004237 

Paper 58 – Increased stillbirths in India

Stillbirths were significantly increased during the pandemic in a large New Delhi hospital compared with the previous year (click here or ijgo.13564). Citation: Kumar, M., Puri, M., Yadav, R., Biswas, R., Singh, M., Chaudhary, V., Jaiswal, N. and Meena, D. (2021), Stillbirths and the COVID‐19 pandemic: Looking beyond SARS‐CoV‐2 infection. Int J Gynecol Obstet. https://doi.org/10.1002/ijgo.13564

Update 27 February – Papers 56 and 57 added

Paper 57 – Slightly fewer preterm births in Pittsburg

At University of Pittsburgh Medical Centres, Magee-Womens Hospital, births <37 weeks fell from 11.1% (1 Jan 2018 to 31 Jan 2020 pre-pandemic) to 10.1% (1 April 2020 to 27 October 2020 pandemic) (click here or 1-s2.0-S2589933321000252-main). Citation: Lara Lemon, Robert P. Edwards, Hyagriv N. Simhan. What is driving the decreased incidence of preterm birth during the COVID-19 pandemic? American Journal of Obstetrics & Gynecology MFM (2021), doi: https://doi.org/10.1016/j.ajogmf.2021.100330&nbsp;

Paper 56 – Effect of lockdown in Beijing, China

No major effects seen (click here or e047900.full). Citation: Du M, Yang J, Han N, et alAssociation between the COVID-19 pandemic and the risk for adverse pregnancy outcomes: a cohort studyBMJ Open 2021;11:e047900. doi: 10.1136/bmjopen-2020-047900

Update 25 February – paper 55 added

Paper 55 – HSIB first wave maternal death report

The UK Healthcare Safety Investigation Branch (HSIB) reviewed 20 maternal deaths (19 included in review) that occurred between 1 March and and 31 May 2020 (the first peak of the COVID-19 pandemic in England) (click here or HSIB_Maternal_Death_Report_V13). Citation: National Learning Report. Maternal death: learning from maternal death investigations during the first wave of the COVID-19 pandemic. Independent report by the Healthcare Safety Investigation Branch I2020/017. February 2021. 

Update 21 February – paper 54 added

Paper 54 – Delayed diagnosis of ectopic pregnancy in Israel

From Shaare Zedek Medical Center, Jerusalem (click here or ijgo.13647). Citation: Barg M, Rotem R, Mor P, Rottenstreich M, Fayez K, Grisaru-Granovsky S, Armon S. Delayed presentation of ectopic pregnancy during the COVID-19 pandemic: A retrospective study of a collateral effect. Int J Gynaecol Obstet. 2021 Feb 18. doi: 10.1002/ijgo.13647. Epub ahead of print. PMID: 33599285.

Update 13 February – paper 53 added

Paper 53 – no effect of pandemic on assisted reproduction outcomes in Italy

From Lombardy (click here or LeviSetti preprint 2021). Citation: Paolo Emanuele Levi-Setti, Federico Cirillo, Valentina Immediata et al. First Trimester Pregnancy Outcomes in a Large&nbsp;ART Center From the Lombardy County (Italy) During the Peak COVID-19 Pandemic., 08 February 2021, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-152522/v1]

Update 1 February – paper 52 added

Paper 52 – first wave hospital births in Israel

Poster presented at the Society of Materno-Fetal Medicine 2021 conference (SMFM 2021) . Fewer hospital births, and higher induction and Caesarean rates during the first wave at Shaare Zedek Medical Center in Jerusalem. Citation to follow.

Update 13 January – paper 51 added

Paper 51 – no association with preterm birth or stillbirth in Sweden

In this national registry study there was no increase in preterm births, or in stillbirths, over the period 1 April through 31 May 2020, compared with the same period over the previous five years (click here or m20-6367). Citation: Pasternak B, Neovius M, Söderling J, Ahlberg M, Norman M, Ludvigsson JF, Stephansson O. Preterm Birth and Stillbirth During the COVID-19 Pandemic in Sweden: A Nationwide Cohort Study. Ann Intern Med. 2021 Jan 12. doi: 10.7326/M20-6367. Epub ahead of print. PMID: 33428442.

Update 9 January – paper 50 added

Paper 50 – fewer & later pregnancy terminations in Texas

The effect of an executive order between March 22 and April 21, to postpone surgery that was not medically necessary, and which was interpreted by some as including abortion, is described (click here or jama_white_2021_ld_200123_1609269106.91809). Citation: White K, Kumar B, Goyal V, Wallace R, Roberts SCM, Grossman D. Changes in Abortion in Texas Following an Executive Order Ban During the Coronavirus Pandemic. JAMA. Published online January 04, 2021. doi:10.1001/jama.2020.24096

Update 2 January – paper 49 added

Paper 49 – more ruptured ectopics during first wave

The ratio of ruptured to unruptured ectopic pregnancies rose between March 15th and May 17th 2020 at Lenox Hill Hospital, New York (click here or ijcp.13925). Citation: Werner, S, Katz, A. Change in ectopic pregnancy presentations during the covid‐19 pandemic. Int J Clin Pract. 2020; 00:e13925. https://doi.org/10.1111/ijcp.13925

Update 23 December – Paper 48 added

Paper 48 – No major adverse effect of lockdown in Botswana

No increase in adverse perinatal outcomes during or after lockdown in Botswana. Rather, a modest reduction, driven primarily by reduced preterm birth and growth restriction (click here or caniglia AJOG 2020 (002)). Time period of lockdown validated against Facebook geolocation data. Citation: CANIGLIA EC, MAGOSI LE, ZASH R, DISEKO M, MAYONDI G, MABUTA J, POWIS K, DRYDEN-PETERSON S, MOSEPELE M, LUCKETT R, MAKHEMA J, MMALANE M, LOCKMAN S, SHAPIRO R, Modest reduction in adverse birth outcomes following the COVID-19 lockdown, American Journal of Obstetrics and Gynecology (2021), doi: https://doi.org/10.1016/j.ajog.2020.12.1198.

Update 19 December – papers 46 and 47 added

Paper 47 – Antenatal care during lockdown in Ethiopia

Pregnant women attending ANC services at public hospitals in Northeast Ethiopia between February 2 & August 30, 2020 (click here or ijwh-287534-antenatal-care-service-utilization-of-pregnant-women-attendi). No control group. Citation: Tadesse E. Antenatal Care Service Utilization of Pregnant Women Attending Antenatal Care in Public Hospitals During the COVID-19 Pandemic Period. Int J Womens Health. 2020;12:1181-1188. Published 2020 Dec 8. doi:10.2147/IJWH.S287534

Paper 46 – Fewer planned moderately preterm births in an Australian hospital

During the 2020 lockdown, rates of planned (iatrogenic) moderately preterm birth fell in the Mater Mothers’ Hospital, South Brisbane, Queensland (click here or 2020.11.24.20237529.full). Outcomes not reported. Citation: Linda A. Gallo, Tania F. Gallo, Danielle J. Borg, Karen M. Moritz, Vicki L. Clifton, Sailesh KumarPreterm birth rates in a large tertiary Australian maternity centre during COVID-19 mitigation measures medRxiv 2020.11.24.20237529; doi: https://doi.org/10.1101/2020.11.24.20237529

Update 15 December – paper 45 added

Paper 45 – fewer visits during lockdown in Nanjing, China

Hospital visits for pregnancy care fell during lockdown in Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, China grid.452290.8 (click here or 10.1177_0300060520939337). There were no reported harms. Citation: Gu XX, Chen K, Yu H, Liang GY, Chen H, Shen Y. How to prevent in-hospital COVID-19 infection and reassure women about the safety of pregnancy: Experience from an obstetric center in China. J Int Med Res. 2020;48(7):300060520939337. doi:10.1177/0300060520939337

Update 14 December – paper 44 added

Paper 44 – increased stillbirths during 1st wave in Israel

Stillbirth were increased in the period  February 21 to April 30 2020, compared with the corresponding periods for 2017 to 2019 in Shamir Medical Center, Zerifin, Israel (click here or s-0040-1721515). Citation: Matan Mor, Nadav Kugler, Eric Jauniaux, Moshe Betser, Yifat Wiener, Howard Cuckle, Ron Maymon. Impact of the COVID-19 Pandemic on Excess Perinatal Mortality and Morbidity in Israel. Am J Perinatol DOI: 10.1055/s-0040-1721515

Update 10th December – paper 43 added

Paper 43 – rise in the rate of ruptured ectopic pregnancies

In Sant’Orsola-Malpighi University Hospital in Bologna, Italy, the rate of ruptured ectopic pregnancies normally 52/201 (26%) rose to 6/9 (66%) during the first lockdown period (click here or uog.22126). Citation: Casadio, P., Youssef, A., Arena, A., Gamal, N., Pilu, G. and Seracchioli, R. (2020), Increased rate of ruptured ectopic pregnancy in COVID‐19 pandemic: analysis from the North of Italy. Ultrasound Obstet Gynecol, 56: 289-289. https://doi.org/10.1002/uog.22126

Update 8th December – papers 41 and 42 added

Paper 42 – no significant alteration in stillbirths during first wave in England

There was no significant alteration in stillbirths overall, or in any region of the UK during the first wave (click here or jama_stowe_2020_ld_200113_1607178377.6775) Citation: Stowe J, Smith H, Thurland K, Ramsay ME, Andrews N, Ladhani SN. Stillbirths During the COVID-19 Pandemic in England, April-June 2020. JAMA. Published online December 07, 2020. doi:10.1001/jama.2020.21369

Paper 41- no significant alteration in preterm births or in stillbirths during first wave in Philadelphia

There were no significant alterations in the patterns, or overall rates, of preterm births or stillbirths during the first wave, in two Philadelphia hospitals (click here or jama_handley_2020_ld_200111_1607178374.44311 (1)). Citation: Handley SC, Mullin AM, Elovitz MA, et al. Changes in Preterm Birth Phenotypes and Stillbirth at 2 Philadelphia Hospitals During the SARS-CoV-2 Pandemic, March-June 2020. JAMA. Published online December 07, 2020. doi:10.1001/jama.2020.20991

Update 7th December – paper 40 added

Paper 40 – 16 maternal deaths in Indonesia

From March to May 2020, 16 pregnant or postnatal women died in West Sumatra (click here or 10.1080@0167482X.2020.1779216). It is not reported whether these were caused by Covid-19 or other diseases. Citation: Mijke Lambregtse-van den Berg, Julie Quinlivan. (2020) Identifying pregnant women at risk of developing COVID-19 related mental health problems – a call for enhanced psychoeducation and social support. Journal of Psychosomatic Obstetrics & Gynecology 41:4, pages 249-250.

Update 5th December – papers 38 and 39 added

Paper 39 – no major obstetric effects of lockdown in Wuhan, China

The Maternal and Child Hospital of Hubei Province (which I believe is part of Huazhong University of Science and Technology Hospital grid.488485.d) observed no major effects of lockdown compared with the previous year (click here or journal.pone.0237420). The Caesarean rate, for example, rose from 47% to 48%. Citation: Li M, Yin H, Jin Z, Zhang H, Leng B, Luo Y, Zhao Y. Impact of Wuhan lockdown on the indications of cesarean delivery and newborn weights during the epidemic period of COVID-19. PLoS One. 2020 Aug 13;15(8):e0237420. doi: 10.1371/journal.pone.0237420. PMID: 32790709; PMCID: PMC7425855.

Paper 38 – reduced prenatal diagnosis procedures Trabzon, Turkey

Between 11 March and 30 June 2020 prenatal dignosis procedures reduced by about one third at Karadeniz Perinatology Clinic, compared with the same period in the previous year (click here or Effect of COVID 19 pandemic process on prenatal diagnostic procedures (1)). Citation: Mirac Ozalp, Omer Demir, Hümeyra Akbas, Ecem Kaya, Cemre Celik & Mehmet Armagan Osmanagaoglu (2020) Effect of COVID-19 pandemic process on prenatal diagnostic procedures, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1815190

Update 3rd December – paper 37 added

Paper 37 – Reduced hospitalisation & increased maternal & perinatal mortality in Jodhpur, India

Reduced hospitlisation and emergency referrals after lockdown, coincided with increased in-hospital maternal mortality, and late intrauterine fetal death and stillbirth in a group of four hospitals associated with Dr S N Medical College, Jodhpur, India (click here or PIIS2214109X20303193). Citation: 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. Epub 2020 Jul 14. PMID: 32679037.

Update 2nd December – papers 35 and 36 added

Paper 36 – freebirth due to fear of Covid in Iran

A woman from Dezful, Khuzestan province in Iran had a normal birth alone at home because she was fearful of contracting Covid-19 in hospital (click here or IJPS-15-366). Both mother and baby were fine. Citation: Nosratabadi M, Sarabi N, Masoudiyekta L. A Case Report of Vaginal Delivery at Home due to Fear of Covid-19. Iran J Psychiatry. 2020;15(4):366-369. doi:10.18502/ijps.v15i4.4306

Paper 35 – delayed presentation in labour in Sao Paolo, Brazil

In São Paulo Hospital betwee March 11 and June 11, more women presented in advanced labour (click here or ijgo.13357). Citation: Sun, S.Y., Guazzelli, C.A.F., de Morais, L.R., Dittmer, F.P., Augusto, M.N., Soares, A.C., Coutinho da Silva, P.M., Abuchaim, E.d.S.V. and Mattar, R. (2020), Effect of delayed obstetric labor care during the COVID‐19 pandemic on perinatal outcomes. Int J Gynecol Obstet, 151: 287-289. https://doi.org/10.1002/ijgo.13357

Update 1st December – papers 32 to 34 added

Paper 34 – reduced risk of post partum depression during lockdown

Rates of raised EPDS scores were reduced during lockdown among women cared for at Soroka University Medical Center, Negev, Israel (click here or Pariente2020_Article_RiskForProbablePost-partumDepr). Citation: Pariente, G., Wissotzky Broder, O., Sheiner, E. et al. Risk for probable post-partum depression among women during the COVID-19 pandemic. Arch Womens Ment Health (2020). https://doi.org/10.1007/s00737-020-01075-3

Paper 33 – breast feeding during lockdown in Belgium

Reported behaviour of a self-selected sample (click here or ijerph-17-06766). Most women reported continuing breast feeding for longer during lockdown. Citation: Ceulemans, M.; Verbakel, J.Y.; Van Calsteren, K.; Eerdekens, A.; Allegaert, K.; Foulon, V. SARS-CoV-2 Infections and Impact of the COVID-19 Pandemic in Pregnancy and Breastfeeding: Results from an Observational Study in Primary Care in Belgium. Int. J. Environ. Res. Public Health 2020, 17, 6766.

Paper 32 – sexual behaviour during lockdown in China

Reported behaviour of a self-selected sample (click here or pdf (1)). Citation. Li G, Tang D, Song B, Wang C, Qunshan S, Xu C, Geng H, Wu H, He X, Cao Y. Impact of the COVID-19 Pandemic on Partner Relationships and Sexual and Reproductive Health: Cross-Sectional, Online Survey Study. J Med Internet Res. 2020 Aug 6;22(8):e20961. doi: 10.2196/20961. PMID: 32716895; PMCID: PMC7419154.

Update 27 November – paper 31 added

Paper 31 – effect of lockdown in Karnataka, India

The self-reported effects of lockdown of 290/315 pregnant women attending Shri B.M. Patil Medical College, Hospital and Research Center, Vijayapura, Karnataka, India, between 21/05/2020 & 08/06/2020 (click here or pmr-12-03-3). Citation: Dr. Rajasri G. Yaliwal, Dr. Aruna M.Biradar, Dr. Shreedevi S. Kori, Dr. Subhashchandra, R. Mudanur, Dr. Shivakumar U. Pujeri, Dr. Shailaja R. Bidri, Dr. Neelamma G. Patil. CHALLENGES OF PREGNANCY DURING THE COVID19 PANDEMIC AND LOCKDOWN –A CROSS-SECTIONAL STUDY. Pravara Med Rev; September 2020, 12(03) , 23-30 DOI: 10.36848/PMR/2020/13100.51291

Update 26 November – papers 29 and 30 added

Paper 30 – more women not receiving antenatal care in Jordan

The self-reported rate of women not receiving antenatal care in this online survey of self-selected members of women’s and motherhood groups in Jordan, rose from a recalled 38/944 (4%) before lockdown to 562 (60%) during lockdown (click here or ijwh-280342-pregnancy-during-covid-19-outbreak-the-impact-of-lockdown-i). Citation: Muhaidat N, Fram K, Thekrallah F, Qatawneh A, Al-Btoush A. Pregnancy During COVID-19 Outbreak: The Impact of Lockdown in a Middle-Income Country on Antenatal Healthcare and Wellbeing. Int J Womens Health. 2020;12:1065-1073 https://doi.org/10.2147/IJWH.S280342

Paper 29 – couples delaying conception in Shanghai, China

Of 447 couples who had been recorded before the pandemic as planning to conceive a pregnancy, 151 (34%) stated that they had altered their plans, presumably in the direction of cancelling or delaying trying for a baby (click here or ijgo.13366). Citation: Zhu, C., Wu, J., Liang, Y., Yan, L., He, C., Chen, L. and Zhang, J. (2020), Fertility intentions among couples in Shanghai under COVID‐19: A cross‐sectional study. Int. J. Gynecol. Obstet., 151: 399-406. https://doi.org/10.1002/ijgo.13366

Update 24th November – paper 28 added

Paper 28 – fewer & later attendances in pregnancy during first wave in Israel

Fewer pregnant women attended the emergency department during the first wave compared with the same period in the previous year, and those that did attended at later gestations or at more advanaced stages of labour. Hower, no differences were seen in outcomes (click here or Changes in the obstetrical emergency department profile during the COVID 19 pandemic). From author affiliations this was probably Carmel Medical Center, Haifa, Israel. Citation: Nir Kugelman, Ofer Lavie, Wisam Assaf, Nadav Cohen, Lena Sagi-Dain, Mordehai Bardicef, Reuven Kedar, Amit Damti & Yakir Segev (2020) Changes in the obstetrical emergency department profile during the COVID-19 pandemic, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1847072

Update 23rd November – paper 27 added

Paper 27 – cancelled clinic appointments in Iran

57/103 pregnant or post-partum women reported cancelling clinic appointments for themselves or their child during lockdown (click here or ijerph-17-08272). Participants were patients in the Department of Gynecology and Midwifery of the Arak University of Medical Sciences, Arak, Iran. Citation: Shayganfard, M.; Mahdavi, F.; Haghighi, M.; Sadeghi Bahmani, D.; Brand, S. Health Anxiety Predicts Postponing or Cancelling Routine Medical Health Care Appointments among Women in Perinatal Stage during the Covid-19 Lockdown. Int. J. Environ. Res. Public Health 2020, 17, 8272.

Update 20 November – paper 26 added

Paper 26 – no alteration in miscarriage rate after embryo transfer in New York

The authors of this conference abstract report that early pregnancy loss rates did not alter during the first wave of the SARS-CoV-2 pandemic (click here or PIIS0015028220323165). Citation: Flisser, Eric et al. PREGNANCY LOSS RATES AFTER SINGLE, EUPLOID FROZEN-THAWED EMBRYO TRANSFER IN THE COVID-19 ERA. Fertility and Sterility, Volume 114, Issue 3, e561 – e562

Update 14 November – paper 25 added

Paper 25 – more stillbirths & fewer late preterm births in Rome, Italy

Using the Lazio region hospital discharge database, the authors report fewer 32-36w births, & more stillbirths in March to May 2020, compared with the same period 2019 (click here or archdischild-2020-320682.full). Citation: De Curtis M, Villani L, Polo A. Arch Dis Child Fetal Neonatal Ed Epub ahead of print: doi:10.1136/archdischild-2020-320682 Accepted 21 October 2020 Arch Dis Child Fetal Neonatal Ed 2020;0:F1. doi:10.1136/fetalneonatal-2020-320682

Update 12 November – papers 22 to 24 added

Paper 24 – hospital births and postnatal depression scores in Hong Kong

Queen Mary Hospital, Pokfulam, Hong Kong observed a fall in hospital births and raised rates of Edinburgh postnatal depression scores over 10 during lockdown (click here or hkmj208774). Citation: PW Hui, Grace Ma, Mimi TY Seto, KW Cheung. Effect of COVID-19 on delivery plans and postnatal depression scores of pregnant women. Hong Kong Med J 2020;26:Epub 5 Nov 2020 https://doi.org/10.12809/hkmj208774

Paper 23 – stress during lockdown in Cork, Ireland

This survey reported no major differences in a range of self-reported psychological or behavioural outcomes during lockdown (click here or 1-s2.0-S187151922030367X-main). Citation: Karen Matvienko-Sikar, Johanna Pope, Avril Cremin, Hayley Carr, Sara Leitao, Ellinor K. Olander, Sarah Meaney. Differences in levels of stress, social support, health behaviours, and stress-reduction strategies for women pregnant before and during the COVID-19 pandemic, and based on phases of pandemic restrictions, in Ireland. Women and Birth. 2020,ISSN 1871-5192, https://doi.org/10.1016/j.wombi.2020.10.010. (http://www.sciencedirect.com/science/article/pii/S187151922030367X)

Paper 22 – lockdown did not affect miscarriage rates in Montreal, Canada

There was no difference in miscarriage/non-viable pregnancy rates in this Montreal fertility unit, between the period of the first wave, and an equivalent period in 2019 (click here or Rotshenker-Olshinka2020_Article_COVID-19PandemicEffectOnEarlyP). Citation: Rotshenker-Olshinka, K., Volodarsky-Perel, A., Steiner, N. et al. COVID-19 pandemic effect on early pregnancy: are miscarriage rates altered, in asymptomatic women?. Arch Gynecol Obstet (2020). https://doi.org/10.1007/s00404-020-05848-0 3 March update. This is the full report of paper 15 (abstract)

Update 10th November – paper 21 added

Paper 21 – shorter postnatal stay during pandemic in Los Angles

Women and babies who delivered in March and April 2020 at Cedars-Sinai Medical Center, Los Angeles, California, USA, had significantly reduced postpartum stays than those in prepandemic periods (click here or Greene AJOG MFM-main). No adverse effects were reported. Citation: Greene NH, Kilpatrick SJ, Wong MS, et al. Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic. Am J Obstet Gynecol MFM 2020;2:100234. https://doi.org/10.1016/j.ajogmf.2020.100234

Update 9th November – papers 19 and 20 added

Paper 20 – halving of emergency admissions during the pandemic in Bologna, Italy

In March 2020, the middle of the COVID-19 pandemic, emegency room attendances halved compared with March 2019 in S.Orsola-Malpighi University Hospital of Bologna (click here or Salsi AJOG MFM). Citation: Ginevra Salsi, Anna Seidenari, Josefina Diglio, Federica Bellussi, Gianluigi Pilu, Federica Bellussi. Obstetrics and gynecology emergency services during the coronavirus disease 2019 pandemic. American Journal of Obstetrics & Gynecology MFM, Volume 2, Issue 4, Supplement, 2020, 100214, ISSN 2589-9333, https://doi.org/10.1016/j.ajogmf.2020.100214. (http://www.sciencedirect.com/science/article/pii/S2589933320301828)

Paper 19 – halving of admissions & births during the pandemic in Jodhpur, India

Over the period of the pandemic, hospital admissions in pregnancy, and hospital births halved in the All India Institute of Medical Sciences, Jodhpur, a tertiary referral hospital (click here or ijgo.13457). 32 pregnant women with Covid-19 were included, so this paper is also included as study 343 here. Citation: Goyal, M., Singh, P., Singh, K., Shekhar, S., Agrawal, N. and Misra, S. (2020), The effect of the COVID‐19 pandemic on maternal health due to delay in seeking health care: Experience from a tertiary center. International Journal of Gynecology & Obstetrics. Accepted Author Manuscript. https://doi.org/10.1002/ijgo.13457

Update 31st October – paper 18 added

Paper 18 – no effect on preterm births in California

No effect on preterm births over the pandemic first wave in California, apart from a small “increase” in births between 28 and 32 weeks (click here or Main AJOG 21 oct 2020 (1)). Citation: Main EK, Chang S-C, Carpenter AM, Wise PH, Stevenson DK, Shaw GM, Gould JB, Preterm birth rates for racial and ethnic groups during the COVID-19 pandemic in California, American Journal of Obstetrics and Gynecology (2020), doi: https://doi.org/10.1016/j.ajog.2020.10.033.

Update 24 October – papers 16 and 17 added

Paper 17 – reduced general anaesthesia for Caesarean during lockdown, UK

Six hospitals observed a fall in Caesarean general anaesthesia rates from 7.7 to 3.7% during the pandemic (click here or ). Citation; Bhatia K, Columb M, Bewlay A, Eccles J, Hulgur M, Jayan N, Lie J, Verma D, Parikh R. The effect of COVID-19 on general anaesthesia rates for caesarean section. A cross sectional analysis of six hospitals in the north-west of England. Anaesthesia. 2020 Oct 18. doi: 10.1111/anae.15313. Epub ahead of print. PMID: 33073371.

Paper 16 – reduced preterm birth in a Philadelphia hospital

In Thomas Jefferson University Hospital preterm birth fell from 13% in March 1-July 31 2019, to 10% in March 1-July 31 2020 (click here or berghella AJOGMFM). Citation: Berghella V, Burd J, Anderson K, Boelig R, Roman A, Decreased incidence of preterm birth during COVID-19 pandemic, American Journal of Obstetrics & Gynecology MFM (2020), doi: https://doi.org/10.1016/j.ajogmf.2020.100258.

Update 20 October – papers 13 to 15 added

Paper 15  – miscarriage before and during lockdown in Montreal, Canada

No change (click here or main (4)) Citation: Olshinka KR, Volodarsky-Perel A, Steiner N, Rubenfeld ES, Dahan MH. COVID-19 PANDEMIC EFFECT ON EARLY PREGNANCY – ARE MISCARRIAGE RATES ALTERED, IN ASYMPTOMATIC WOMEN?. Fertil Steril. 2020;114(3):e525-e526. doi:10.1016/j.fertnstert.2020.09.036 March 3rd update. The full version of this abstract is reported in paper 22.

Paper 14 – diabetes control during lockdown in Lille, France

It deteriorated (click here or main (3)). Citation: Ghesquière L, Garabedian C, Drumez E, et al. Effects of COVID-19 pandemic lockdown on gestational diabetes mellitus: A retrospective study [published online ahead of print, 2020 Oct 15]. Diabetes Metab. 2020;doi:10.1016/j.diabet.2020.09.008

Paper 13 – the Covid-19 New Mum survey

Self-selected and self-reported UK maternal birth experiences before and after lockdown (click here or main (2)). Citation: A. Vazquez-Vazquez, Appetite, https://doi.org/10.1016/j.appet.2020.104985

Update 18 October – papers 10 to 12 added

Paper 12 – reduced preterm birth in The Netherlands

National study based on dried blood spot screening programme (click here or PIIS2468266720302231). Citation: Been, Jasper V et al. Impact of COVID-19 mitigation measures on the incidence of preterm birth: a national quasi-experimental study. The Lancet Public Health, Volume 0, Issue 0. https://doi.org/10.1016/S2468-2667(20)30223-1

Paper 11 – reduced preterm births in Dublin, Ireland

There was a small reduction in preterm birth, but no other effects, between 1st January & 31st July 2020 compared to the same period in 2019 in the Coombe Women & Infants University Hospital (click here or PIIS0301211520306539). Citation: McDonnell S, McNamee E, Lindow SW, O’Connell MP, The impact of the Covid-19 pandemic on maternity services: a review of maternal and neonatal outcomes before, during and after the pandemic, European Journal of Obstetrics and amp; Gynecology and Reproductive Biology (2020), doi: https://doi.org/10.1016/j.ejogrb.2020.10.023

Paper 10 – reduced preterm births in Israel (update 3 March)

This preprint consists only of results tables (click here or PIIS0002937820311911 (1)). The corresponding author is from Chaim Sheba Medical Center, Israel. Citation: Meyer R, Friedrich L, Maixner N, Bart Y, Tsur A, Yinon Y, Levin G, A marked decrease in Preterm Deliveries during the COVID-19 Pandemic, American Journal of Obstetrics and Gynecology (2020), doi: https://doi.org/10.1016/j.ajog.2020.10.017. Update 3 March. This paper (click here or 244117) with overlapping authorship, also reports the effect of lockdown in the same hospital. Citation:  Meyer R, Levin G, Hendin N, Katorza E. Impact of the COVID-19 Outbreak on Routine Obstetrical Management. Isr Med Assoc J. 2020 Aug;22(8):483-488. PMID: 33236580.

Update 12 October – papers 8 and 9 added

Paper 9 – effect of lockdown in one hospital in Israel

Various pregnancy complications  over March–April 2020 (the peak COVID-19 outbreak) in one large hospital, were compared with March–April 2019 in the same hospital (click here or 231152 (002)). From author affiliations the hospital was probably Rambam Health Care Campus in Haifa. Citation: Justman N, Shahak G, Gutzeit O, Ben Zvi D, Ginsberg Y, Solt I, Vitner D, Beloosesky R, Weiner Z, Zipori Y. Lockdown with a Price: The impact of the COVID-19 Pandemic on Prenatal Care and Perinatal Outcomes in a Tertiary Care Center. Isr Med Assoc J. 2020 Sep;9(22):467-471. PMID: 32954690.

Paper 8 – effect of lockdown in one hospital in Japan

The rates of women hospitalised for some pregnancy complications in Keio University Hospital between April 1st and June 30th, 2020, were compared with the same period 2017-19 (click here or jog.14518). No substantive outcomes reported. Citation: Kasuga, Y., Tanaka, M. and Ochiai, D. (2020), Preterm delivery and hypertensive disorder of pregnancy were reduced during the COVID‐19 pandemic: A single hospital‐based study. J. Obstet. Gynaecol. Res.. doi:10.1111/jog.14518

Update 9 October – papers 6 and 7 added

Paper 7 – reduced admission to emergency OBGYN during first wave in Milan, Italy

Between February 24th & May 31st 2020 emergency OBGYN admissions decreased by 35% at Clinica Mangiagalli, the largest maternity clinic in Milan, compared with the corresponding period in 2019   (click here or 1-s2.0-S0301211520305777-main). Five fetal deaths were seen in the emergency clinic in the pandemic period compared with one in the earlier period. Total perinatal deaths were not reported for either period. Citation: Chiara Dell’Utri, Elisabetta Manzoni, Sonia Cipriani, Claudio Spizzico, Andrea Dell’Acqua, Giussy Barbara, Fabio Parazzini, Alessandra Kustermann. Effects of SARS Cov-2 epidemic on the obstetrical and gynecological emergency service accesses. What happened and what shall we expect now? European Journal of Obstetrics & Gynecology and Reproductive Biology, Volume 254, 2020, Pages 64-68, ISSN 0301-2115, https://doi.org/10.1016/j.ejogrb.2020.09.006.&nbsp;

Paper 6 – four maternal deaths from suicide & two women murdered during UK lockdown

Four women died from suicide during pregnancy or soon after birth and two recently pregnant women died from domestic violence in the UK, between 01/03/2020 and 31/05/2020,causes (click here or ref.-201-mbrrace-uk-maternal-covid-19-report-final-002)). Citation: Knight M, Bunch K, Cairns A, Cantwell R, Cox P, Kenyon S, Kotnis R, Lucas DN, Lucas S, Marshall L, Nelson-Piercy C, Page L, Rodger A, Shakespeare J, Tuffnell D, Kurinczuk JJ on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care Rapid Report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK March – May 2020 Oxford: National Perinatal Epidemiology Unit, University of Oxford 2020.

Paper 5 – no change in extremely preterm births during lockdown in the SafeBoosC-III consortium trial centres

In this Medxiv preprint the rate of extremely preterm births (<28 weeks) in 46 neonatal intensive care units participating in the SafeBoosC-III trial, did not alter during the three months of most rigorous lockdown, compared with the corresponding three months of 2019 (click here or 2020.10.02.20204578v1.full). Citation: Marie Isabel Rasmussen, Mathias Luehr Hansen, Gerhard Pichler, Eugene Dempsey, Adelina Pellicer, Afif EL-Khuffash, Shashidhar A, Salvador Piris-Borregas, Miguel Alsina, Merih Cetinkaya, Lina Chalak, Hilal Ozkan, Mariana Baserga, Jan Sirc, Hans Fuchs, Ebru Ergenekon, Luis Arruza, Amit Mathur, Martin Stocker, Olalla Otero-Vaccarello, Tomasz Szczapa, Kosmas Sarafidis, Barbara Krolak-Olejnik, Asli Memisoglu, Hallvard Reigstad, Elzbieta Rafinska-Wazny, Eleftheria Hatzidaki, Zhang Peng, Despoina Gkentzi, Renaud Viellevoye, Julie De Buyst, Emmanuele Mastretta, Ping Wang, Gitte Hahn, Lars Bender, Luc Cornette, Jakub Tkaczyk, Ruth del Rio, Monica Fumagalli, Evangelina Papathoma, Maria Wilinska, Gunnar Naulers, Iwona Sadowska-Kakrawczenko, Chantal Lecart, Maria Luz Couce, Siv Fredly, Anne Marie Heuchan, Tanja Karen, Gorm Greisen Extremely preterm infant admissions within the SafeBoosC-III consortium during the COVID-19 lockdown  medRxiv 2020.10.02.20204578; doi: https://doi.org/10.1101/2020.10.02.20204578

Paper 4 – fall in very & extremely low birthweight infants during lockdown in Limerick, Ireland

The rate of birth of both very low birthweight and extremely low birth weight infants reduced significantly in Jan-April 2020 compared witht the same period over the preceding 10 years (click here or e003075.full). Citation: Philip RKPurtill HReidy E, et al Unprecedented reduction in births of very low birthweight (VLBW) and extremely low birthweight (ELBW) infants during the COVID-19 lockdown in Ireland: a ‘natural experiment’ allowing analysis of data from the prior two decades. 

Paper 3 – halving of hospital births & increased perinatal mortality during lockdown in Nepal

Between Jan 1 and May 30, 2020, births in nine hospitals in Nepal halved during the latter 5 lockdown weeks, and stillbirths and neonatal mortality rose significantly (click here or PIIS2214109X20303454 (1)). Citation: KC, Ashish et al. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study. The Lancet Global Health, Volume 8, Issue 10, e1273 – e1281

Paper 2 – fall in extreme prematurity during lockdown in Denmark

Using a national database the numbers of extremely premature singleton births was significantly lower between 12 March and 14 April 2020 than the previous five years (click here or fetalneonatal-2020-319990). There was no significant difference in other gestational age categories. Citation: Hedermann G, Hedley PL, Bækvad-Hansen M, Hjalgrim H, Rostgaard K, Poorisrisak P, Breindahl M, Melbye M, Hougaard DM, Christiansen M, Lausten-Thomsen U. Danish premature birth rates during the COVID-19 lockdown. Arch Dis Child Fetal Neonatal Ed. 2020 Aug 11:fetalneonatal-2020-319990. doi: 10.1136/archdischild-2020-319990. Epub ahead of print. PMID: 32788391; PMCID: PMC7421710.

Paper 1 – rise in stillbirths at a London hospital

St George’s hospital in South London noted a rise in stillbirths between February 1 & June 14, 2020 compared with the previous four months (click here or jama_khalil_2020_ld_200076). Neonatal deaths were not reported. There were no significant differences in preterm birth rates. Citation: Khalil A, von Dadelszen P, Draycott T, Ugwumadu A, O’Brien P, Magee L. Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic. JAMA. 2020;324(7):705–706. doi:10.1001/jama.2020.12746

Jim Thornton, Keelin O’Donoghue & Kate Walker

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