Reduction of Preterm Births in South West England During The COVID-19 Pandemic: Staff Perceptions Versus Evidence

The COVID-19 lockdown had a series of intended and unintended consequences, including reduced infections, changes in activities and work practices. Some of these changes may have been benecial to perinatal outcomes, however other factors such as reduced access to face-to-face healthcare and/or reluctance to attend hospital for fear of exposure to infection may have contributed negatively to antenatal care. A systematic review suggests that preterm births have not signicantly changed overall, but they have decreased in high-income countries. The aim of this audit was to compare neonatal admissions in the South West of England during 2020 to 2018 and 2019. Anonymised birth and neonatal admission rates from January-December 2020 was obtained and compared to data from 2018–2019. The results demonstrate a decreasing of neonatal unit admissions between 2018–2020 (p = 0.002). However, the reduction in neonatal unit admissions is observed from 2018 and there were no signicant differences across gestational groups. It is unclear without nationwide data whether the trends observed in our audit are generalisable and related to the COVID-19 pandemic. However, the data have clinical signicance and revisiting clinical practices like organisational and workforce issues is warranted. Future research exploring the impact of lockdowns on behaviour change during pregnancy is required to understand the reality of pregnancy and preterm birth.


What Is Known
The COVID-19 lockdown had a series of intended and unintended consequences, some of which may have been bene cial to perinatal outcomes.
Research suggests that preterm births have not signi cantly changed overall, but they have decreased in high-income countries.
What is new: In our audit of regional birth and neonatal admission data from the South West of England there was a decrease in admissions between 2018-2020.
A reduction in neonatal unit admissions was observed from 2018 and there were no signi cant differences across gestational groups.

Background
Since the start of COVID-19 in December 2019, the UK initiated national lockdowns in March 2020 with restrictions gradually released from June 2020 and reinstated in November 2020. The lockdown had a series of intended and unintended consequences, including reduced infections, changes in activities and work practices. During the rst lockdown from March -June 2020, pregnant women were considered a vulnerable group and were recommended to 'shield', by remaining at home at all times. Some of these changes may have been bene cial to perinatal outcomes, however other factors such as reduced access to face-to-face healthcare and/or reluctance to attend hospital for fear of exposure to infection may have contributed negatively to antenatal care [1,2].
Recent studies reported changes in infants born preterm. However, ndings have been inconsistent, likely due to heterogeneous populations, outcomes, and timeframes [3][4][5]. For example, in a study using a nationwide Danish register comparing data from 5162 births between March-April 2020 to the previous 5 years, a signi cantly lower rate of extremely premature infants (0.9 vs 2.19/1000 births) was observed. However, there was no signi cant difference between 2020 and previous years for other gestational age categories [5]. A study from state-wide data in California of 123,853 births which compared data from April-July 2020 to the same timeframe in 2016-2019, found that preterm birth rates remained unchanged except the 28-32 weeks subset, which increased from 6.09 to 11.22/1000 births [4]. This change appeared to be driven primarily by the Hispanic or Latinx population, suggesting there may be ethnic differences in preterm birth/access to healthcare. Looking at data from the UK, a single centre study from a London hospital comparing data from February -June 2020 to October 2019-January 2020 reported no signi cant differences in preterm births or neonatal units (NNU) admissions [3]. Overall, the rst systematic review on this topic has concluded that preterm births before 37 weeks' gestation were not signi cantly changed overall, but were decreased in high-income countries, where spontaneous preterm birth was also decreased [6].
In our NNUs in the South West of England, staff perceived to be less busy in 2020 and speculated whether there had been a reduction in preterm birth in the region in response to the COVID-19 pandemic. The aim of this audit was therefore to compare neonatal admissions during 2020 to previous years (2018 and 2019) to determine whether staff perceptions were corroborated by numbers, considering previous publications nding con icting results.

Methods
Anonymised data were obtained from the South West Neonatal Network (SWNN) registry, which covers an area of 9000 square miles with a population of 4.7 million and a birth rate of ~ 45,000/year. The SWNN records all births and admissions from 12 NNUs. The 12 NNUs include three Neonatal Intensive Care Units admitting babies of all gestations including referrals from the other units. Six Local Neonatal Units admitting babies from 27 weeks gestation, and three Special Care Units admitting babies from 32 weeks gestation.
We analysed data of births and neonatal admissions during 2020 and compare these with data from 2018-2019. The number of admissions of all extremely and very preterm (< 31 + 6 weeks), late preterm (31 + 6 -36 + 6 weeks) and term (> 36 + 6 weeks) births occurring between the 1st January and 31st December 2020 was determined and compared to the 12-month in 2018 and 2019. All non-viable at birth with gestational age ≥ 22 weeks and late termination for fetal abnormalities were excluded. The number of neonatal admissions as a percentage of live births was calculated as a whole and per gestational subgroup. The relationship between the number of and category of neonatal admissions and year was assessed using chi-squared tests.

Discussion
The aim of this audit was to compare neonatal admissions in the South West of England during 2020 to previous years to determine whether staff perceptions of NNUs being less busy were corroborated by admission data. We found a decrease in NNU admissions from 2018-2020, con rming neonatal staff perceptions. However interestingly the decrease between 2018 and 2019 was larger than the difference between 2019 and 2020, implying that the COVID-19 lockdown was not necessarily implicated. Additionally, we found no signi cant difference in admissions across gestational groups, similar to a single-site UK-based study [3] and data from Philadelphia and Israel [7,8]. However, these ndings are in disagreement with data from other developed countries such as Italy, Ireland and the Netherlands [6, [9][10][11].
Between 2010-2019 the rate of preterm live births in the UK has been between 7%-8%. Reducing preterm birth is a national health priority in the UK, with an aim to reduce rates from 8-6% by 2025 [12]. The current strategy to improve preterm birth rates focus on three key areas of care provision: prediction, prevention and preparation of women at high-risk preterm birth. As most morbidity and mortality is associated with births < 34 weeks gestation, even extending gestation for a few further weeks and reducing a relatively small number of preterm births, could have demonstrable impact on health outcomes, as well as cost and resource savings. The drop in NNU admissions in our audit is already evident from 2018 to 2019 and may be re ective of organisational and policy changes to improve preterm rates, in advance of any potential impact of national lockdown restrictions due to the COVID-19 pandemic.
We recognise that the limitation of our observations is reliant on a crude analysis of retrospective data and do not include possible explanatory factors, including induction of labour and/or other obstetric complications. Additionally, we did not include COVID-19 infection rates in our analysis. The UK incidence admission rate with con rmed SARS-CoV-2-infection in pregnancy has been recorded at 4.9/1000 [13]. However, overall COVID-19 infection rates in the South West of England have been relatively low compared to the rest of the UK, concurring the hypothesis that infection is not implicated in our observed trends.
We chose to include a full 12 months of data during the COVID-19 pandemic (January -December 2020), unlike other studies, as there is now emerging evidence that COVID-19 infection is likely to have been circulating prior to the o cial lockdown in March 2020. Data from years prior to 2018 were not included to enable us to demonstrate a long-term trend, however other studies examined a similar timeframe [7,9,10]. It is unclear without nationwide data whether the trends observed in our audit are generalisable. The South West of England has a predominantly white ethnic population, so does not necessarily re ect the more diverse population of the UK.
We aim to monitor the data of 2021 and beyond to understand and investigate possible effects of the extended lockdown period during the COVID-19 pandemic. However, our data have clinical signi cance and revisiting clinical practices like organisational and workforce issues is warranted. Future research exploring the impact of lockdowns on behaviour change during pregnancy is required to understand the reality of pregnancy and preterm birth. Admission trends to South West Neonatal Units between 2018-2020, overall and by gestational subgroup. NNU=Neonatal Unit.