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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 and the town is dirty and smoky, but 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 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’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 @VikiLovesFACS is doing so here.

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

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: 

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. 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:

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. 

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. 

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.

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. 

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.

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.




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).


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). 


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).


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). 


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). 


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).


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).


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). 


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.


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.


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 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.



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 updated 27th February 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 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: 

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 []

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.

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:

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:

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.

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.

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).

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

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.

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

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, (

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).

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.

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, (

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.

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:

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:

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

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,

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.

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:

Paper 10 – reduced preterm births in Israel 

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: 

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, 

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:

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

Beth Rowley

September 27, 2020

Supporting artists during lockdown


If your spine tingled to the introductory music to the BBC drama Strike (click here) you’re a Beth Rowley fan. She comes from my birthtown, Bristol, and has released two albums. I think she’s right up there with Adele and Amy Winehouse. But it was through Strike that I discovered her. Normally I’d have played her on Spotify and checked if she ever performed near Nottingham. But she won’t be touring now.

Until streaming came along, musicians used to make most of their money from LP & CD sales. Then live performance took over, surely a good thing.  Now that has stopped we need to go back to buying CDs. Her latest Gota Fria is £11.99 on Amazon, and an extra 95p on her own website. I love Amazon but they are doing well out of lockdown. I still have a job and less to spend my money on, so the latter it was (click here).

It’s a wonderful record. Time to buy Little Dreamer.

Jim Thornton

OASI care bundle evaluation project

September 23, 2020

A well-conducted study, but an unclear result

I admit it. I was sceptical. A stepped wedge (type of cluster) trial evaluating a “care bundle” (leaflets, a manoevre called the “Finnish grip”, 60o episiotomy & routine rectal examination) with, at best, a shaky evidence base (click here & here), evaluated by researchers who clearly already believed in it, and driven by two political organisations (RCM & RCOG) whose leaders felt that “something must be done” and were claiming success even before it started (2016 links no longer available). When the project ended, and more press releases announced success (2018 links not available), without any results appearing for over two years, I feared the worst; sample size changes, centres excluded for “low compliance”, participants disappearing from analysis groups, outcome switching, statistical shenanigans.

The “Finnish grip” is a bit odd too. Although mentioned on the Care Bundle website (click here), it doesn’t appear in the protocol or trial registry – I did a word search. Both call the 3rd element “Manual perineal protection”. The “Finnish grip” is mentioned, but not described, in the main trial report, and the references cited as sources (click here and here) describe it as “a technique for guiding the head through the introitus by gripping the baby’s chin with a flexed middle finger of the other hand”. They both refer to (Pirhonen et al 1998 click here) as the original source. In 1998 Jouko Pirhonen was a trainee in Lund, Sweden, and he is now a professor in Oslo, Norway. But Pirhonen is a Finnish name, and his co-authors included three obstetricians (no midwives) from Finland. They wrote:

“The delivery assistant presses the baby’s head with her left hand to control the speed of crowning through the vaginal introitus. Simultaneously, using the thumb and index finger of the right hand to support the perineum while the flexed middle finger is used to take a grip on the baby’s chin. When a good grip has been achieved, the woman is asked to stop pushing, to breathe rapidly, while the midwife slowly helps baby’s head through the vaginal introitus. When most of the head is out, the perineal ring is pushed under the baby’s chin.”

This is anatomically impossible, unless the flexed middle finger enters the rectum – surely they don’t mean that! – and even then it would be a stretch to reach the chin. Something probably got lost in translation. In practice it’s likely that midwives using the Care Bundle controlled delivery of the head by perineal pressure and discouraging maternal pushing.

I confess I feared the whole study would shed more heat than light on the topic, and together with a colleague, Hannah Dahlen, wrote a grumbling opinion piece (click here).

But the results are in (click here or gurol-urganci), together with a qualitative study of the implementation process (click here or bidwell), and I’m eating my words.

The study was registered (click here), and the protocol published (click here). Registration was a bit late 22/09/2017 – the project ran from 1 October 2016 and 31 March 2018 – but that’s made clear in the paper, and the protocol had been publicly available since January 2017. There’s no reason to believe either was written after peeking at the data.

Four regions, each containing a mixture of different size and type of birth unit were studied over the same 18-month period, with routine data collected all through. Only four randomised units is rather few, but unavoidable due to funding contraints.

Regions were randomised to have the care bundle taught and implemented sequentially over months 4-6, 7-9, 10-12 or 13-15 respectively. These transition periods were excluded from analysis. This left four 3, 6, 9 or 12-month duration baseline phases, and four same duration evaluation phases to compare. The Consort flow diagram, for some reason relegated to supplementary material* (click here), shows the design nicely. Exclusions were all for objective reasons, Caesarean, multiple or still-birth and did not alter over the trial.

All women having a singleton vaginal birth were included and the size of the before and after groups was approximately equal (baseline 27,668, evaluation 27,932). This is reassuring. Differential rates of Caesarean birth, baseline 12,807 (31.6%) v evaluation 12,472 (31.3%), had not muddied the waters.

The primary, indeed the only, endpoint was OASI (obsteric anal sphincter injury) as recorded on the hospital routine database, and the primary analysis was done after statistical adjustment for a range of potentially relevant factors. Here are the relevant methods as reported in the paper.

“We used multi-level logistic regression to estimate adjusted odds ratios (aOR) […]. The regression model included a linear term for calendar time […] a random effect to account for clustering at both region and unit levels and individual case-mix factors (maternal age, ethnicity, body mass index, parity, mode of birth and birthweight).”

And here they are as planned in the protocol.

“We will use logistic mixed effects regression to model the log odds of sustaining an OASI, with a fixed effect for each step and a random effect to account for clustering at the unit level. The model will include a linear secular trend and also adjust for risk factors for OASI (maternal age, BMI, ethnicity, mode of delivery, episiotomy, birthweight, prolonged labour, and shoulder dystocia).”

Perfect. The planned analysis was done.

And the result. The recorded OASI rate decreased from 911/27,668 (3.3%) baseline phase to 817/27392 (3.0%) evaluation phase (aOR 0.80, 95% CI 0.65–0.98) p=0.03.

But what does it mean? Did manual perineal protection prevent 94 women suffering OASI? Did the 60o episiotomy do the trick? Did a few women read the leaflet and, fearful of OASI, choose Caesarean? Or a mixture of all three? Or was the difference in the “diagnosis” of OASI?

The original research, which had inspired the trial, had shown a much larger increase in recorded OASI from 1.8% in 2000 to 5.9% in 2011 (click here). The authors of that study, who included many of the current trial authors, had concluded that “improved recognition of tears following the implementation of a standardised classification of perineal tears was the most likely explanation”. They were surely correct. Diagnosing OASI is not easy. It can be both over and underdiagnosed. An effect size of 0.3% in an endpoint which can vary by 4.1% due “improved recognition” must be susceptible to ascertainment bias.

And this was an “open” trial. Staff may not have realised they were in the baseline phase but they certainly knew about the implementation and evaluation phases. This is from the qualitative study report (click here or bidwell).

“Many participants spoke about a well advertised launch, which created a lot of ‘noise’ and got the project off to a good start: ‘Yes, we had a launch day at the unit….on that day they had many sessions talking about it. We had the models.….they had pictures of how you would give an episiotomy, things like that, to add to this…There was quite a lot of noise about this. (Midwife)'”

“Many talked about the positive and passionate way with which the champions delivered the training. ‘She [the champion] was like a hound! …. if you weren’t trained and you were on her list, she would hunt you down….She would come in early to catch people on night shifts and stuff……If you have somebody like that who is passionate about the training and gets the training done, then I think that’s what makes it better. (Obstetrician)'”

How did midwives and doctors in the midst of such a campaign classify borderline cases?

Consider, for example, a woman with suspected OASI transferred to the operating theatre for repair, who when reviewed under good light by a senior staff member was found to have an intact sphincter? Would the theatre staff recode the planned operation to “repair of episiotomy”? In the baseline phase they might not even have realised the diagnosis had changed. But in the implementation and evaluation phases, with champions “hounding” everyone, the coding surely would be altered. Of course the effect might also have gone in the other direction. Routine rectal examination might have increased diagnosis. We just don’t know.

These doubts matter because the underlying evidence base for each component of the bundle is so weak. Well designed individually randomised trials do not support manual perineal protection (click here), there have been no trials of 60o angle episiotomy, and rectal examination after normal birth in the absence of a tear makes no sense (click here).

We can all support information giving, avoiding midline episiotomies and doing rectal examinations in the presence of tears. But the debate over manual perineal protection, extremely lateral episiotomy, and routine rectal examination even after normal birth with an intact perineum, will surely continue.

Jim Thornton

Footnote. *The Consort flow diagram belongs in the main report, especially for complex designs. Come on BJOG!

An improved martini

September 4, 2020

Not a better recipe, but a better technique – freezing water in the glass

Last week, dipping into Kingsley Amis’s Everyday Drinking (click here) on holiday, I came across this under “the Dry Martini”.

“A couple of hours before the party get your glasses together. They should be on the small side – the second half of a too large martini will have become too warm by the time the average drinker gets to it – and have some sort of stem or base to prevent the hand-imparting warmth. […] Fill each with water and put in the refrigerator.”

I read it as “put in the freezer”. As Amis says.

“It is more important that a cold drink should be as cold as possible than that it should be as concentrated as possible.”

I should have realised that in Amis’s day the freezer section of a domestic fridge would barely hold a tray of ice; no chance even a small martini glass. But I’ve got a modern monster freezer, so undaunted I made my martini. Freezing the water in the glass in emulation, and using a modern vermouth, Regal Rogue – Daringly Dry (click here), to annoy him. Click here for the video. It worked a treat.


Only afterwards did I realise he’d never meant “freeze the ice in the glass”. He wrote.

“While the jug is standing, empty the water out of the glasses and drop a bit of lemon rind in each.”

Nor, from a brief google search, does anyone else. People add ice cubes, sometimes large ones to avoid the over-dilution problem, but never my technique.  I offer it to the world.

Jim Thornton

6 September update

I was wrong, or rather right first time. Amis did advocate freezing water in the glass, albeit ten years later. My volume is a compendium of three books; On Drink (1974), Everyday Drinking (1983) and How’s Your Glass? (1985). The quotations were from On Drink. By the time of Everyday Drinking he must have got a larger freezer. He writes.

“The best Dry Martini known to man is the one I make myself. In the cold part of the refrigerator I have a bottle of gin and a small wineglass, half full of water that has been allowed to freeze.”

“When the hour strikes I half fill the remaining space with gin, flick in a few drops of vermouth and add a couple of cocktail onions, the small white hard kind. Now that is a drink.”

Oh well. Nothing new.

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