key: cord-0291013-iwrekxes
authors: Jones, H.; Seaborne, M.; Cowley, L.; Odd, D. E.; Paranjothy, S.; Akbari, A.; Brophy, S.
title: Population birth outcomes in 2020 and experiences of expectant mothers during the COVID-19 pandemic: a Born in Wales mixed methods study using routine data
date: 2021-08-23
journal: nan
DOI: 10.1101/2021.08.23.21262209
sha: a7499a488dbff2b31f59ddddbfb305f7150e8721
doc_id: 291013
cord_uid: iwrekxes

Background: Pregnancy can be a stressful time and the COVID 19 pandemic has affected all aspects of life. This study aims to investigate the impact of the pandemic on population birth outcomes in Wales, rates of primary immunisations and examine expectant mothers experiences of pregnancy including self reported levels of stress and anxiety. Methods: Population level birth outcomes in Wales: Stillbirths, prematurity, birth weight and Caesarean section births before (2016 to 2019) and during (2020) the pandemic were compared using national level routine anonymised data held in the Secure Anonymised Information Linkage (SAIL) Databank. The first three scheduled primary immunisations were compared between 2019 and 2020. Self reported pregnancy experience: 215 expectant mothers (aged 16+) in Wales completed an online survey about their experiences of pregnancy during the pandemic. The qualitative survey data was analysed using codebook thematic analysis. Findings: There was no significant difference between annual outcomes including gestation and birth weight, stillbirths, and Caesarean sections for infants born in 2020 compared to years 2016 to 2019. There was an increase in late term births (>42 weeks gestation) during the first lockdown (OR: 1.28, p=0.019) and a decrease in moderate to late preterm births (32 to 36 weeks gestation) during the second lockdown (OR: 0.74, p=0.001). Fewer babies were born in 2020 (N=29,031) compared to years 2016 to 2019 (average N=32,582). All babies received their immunisations in 2020, but there were minor delays in the timings of vaccines. Those due at 8 weeks were 8% less likely to be on time (within 28 days) and at 16 weeks, they were 19% less likely to be on time. The pandemic had a negative impact on the mental health of 71% of survey respondents, who reported anxiety, stress and loneliness; this was associated with attending scans without their partner, giving birth alone, and minimal contact with midwives. Interpretation: The pandemic had a negative impact on mothers experiences of pregnancy; however, population level data suggests that this did not translate to adverse birth outcomes for babies born during the pandemic.

The prenatal period is marked by pronounced physiological and psychosocial changes, and previous work has shown that general anxiety, pregnancy-related anxiety, and psychosocial stress are common in pregnant women [1, 2, 3, 4, 5, 6] . Maternal stress and anxiety during pregnancy is also known to be associated with adverse neonatal and obstetric outcomes [7, 8, 9] .

Specifically, anxiety and stress during pregnancy have been associated with premature birth and low birth weight [8, 10, 11] , which are in turn associated with increased risk of neurodevelopmental and respiratory complications [12, 13] , and increased risk of infant mortality [14, 15] . Stress in pregnancy has also been associated with stillbirth [16] and contributes to a higher likelihood of unplanned caesarean delivery and prolonged labour duration via the use of analgesia [17, 18] . The relationship between prenatal anxiety and obstetric outcomes is less clear [19, 20] .

After the World Health Organization (WHO) declared the novel coronavirus (COVID- 19 ) outbreak a global pandemic on 11 March 2020 [21] , public health measures and nonpharmaceutical interventions (i.e. social distancing, lockdowns, self-isolation and shielding) were implemented across the UK in order to control the spread of the virus. These restrictions led to major changes for the delivery of primary and secondary care services, including changes in how antenatal, intra-partum and post-natal care was provided. In Wales, partners were unable to attend antenatal or ultrasound appointments, or to be present during labour and delivery [22] Furthermore, pregnant women may have lacked social support from their friends, family and community due to social distancing and lockdown measures, and routine contact with health visitors during the postnatal period was also disrupted. Many may have taken additional precautions to avoid contact with others, as pregnant women are considered a highrisk population [23] . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ;  https://doi.org/10.1101/2021.08. 23.21262209 doi: medRxiv preprint The 'high-risk' may have affected behaviours (and potential exposure) as the pandemic evolved and numbers of new cases were regularly reported. By month, new cases in Wales started at approximately 2,300 in March, rising to a peak of over 8000 new cases in April.

These numbers approximately halved in May and again in June, falling to the lowest number of 821 new cases in August 2020. September to December increased rapidly to a second peak of over 72,000 new cases in December [24] .

Experiencing pregnancy during a pandemic potentially adds a unique element of additional stress for expectant mothers. Pregnant women may be particularly susceptible to the adverse, indirect effects of the COVID-19 pandemic and associated restrictions [25] .

Pandemic-related stress and adversity may trigger or exacerbate common prenatal mental health conditions. An increasing number of studies worldwide have reported heightened levels of stress and anxiety among pregnant women because of the pandemic and the broad changes to antenatal, intrapartum and postnatal care pathways [26, 27, 28, 29] . However, studies examining neonatal and obstetric outcomes have thus far produced mixed results, with some, but not all, reporting a higher incidence of stillbirths [30, 31] and others reporting decreases in premature births [32, 33, 34] .

While a number of studies have assessed women's experiences of pregnancy during the COVID-19 pandemic [35, 36, 37] , studies conducted in Wales are lacking. In addition, there are a lack of studies examining experiences of pregnancy during the pandemic in combination with national data on objective measures of neonatal and obstetric outcomes.

This study aims to examine the impact of changes in maternity care due to COVID on (a) population birth outcomes including stillbirths, mortality, prematurity, birth weight, rates of Caesarean sections (C-sections) and vaccination rates before and during the pandemic and b) women's experience of pregnancy during the coronavirus pandemic. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint

There were two parts to this study: 1) Analysis of routinely available data on pregnancy and birth outcomes in Wales, before and during the pandemic and 2) An online survey with a subgroup of expectant mothers about their experiences of pregnancy during the COVID-19

pandemic. Expectant mothers aged 16+ living in Wales during the COVID-19 pandemic were invited to complete an online survey via social media advertising. Online consent was taken prior to completion. The survey took approximately 20 minutes to complete. Closed questions were used to ascertain information about participants' demographic characteristics, and whether they had experienced periods of stress, anxiety, or stressful life events during their pregnancy. We used the stress questions from the Pregnancy Risk Assessment Monitoring System (PRAMS) [38] We also used the Patients Health Questionnaire (PHQ-9) [39] and the General Anxiety Disorder (GAD-7) [40] to assess anxiety and depression.

Quantitative survey data were summarised using descriptive statistics. Codebook thematic analysis [41] was used to generate themes from an open-ended question on the survey: 'How would you describe your experience of this pregnancy (support from midwife, how do you feel about being pregnant)?' Thematic analysis identifies and describes patterns across data [42] .

'Codebook' approaches use a structured coding framework to develop and document the analysis [41, 43] . Analysis involved six phases 1) data familiarisation and writing familiarisation notes 2) systematic data coding 3) generating initial themes from coded and collated data 4) developing and reviewing themes 5) refining, defining, and naming themes and 6) writing the report. All data were independently analysed by HJ and LC, who then discussed their findings. This was to ensure that important concepts within the data were not missed, and to achieve a richer understanding of the data through multiple perspectives [41] . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint

A retrospective cohort of babies born in 2016 through to the end of 2020 was created by using linked, electronic health record (EHR) data sources available within the Secure Anonymised Information Linkage (SAIL) Databank [44, 45, 46, 47, 48] . The SAIL Databank is a privacyprotecting trusted research environment (TRE) that holds linked anonymised data sources from ~5-million of the living and deceased population of Wales, that enables longitudinal retrospective and prospective follow-up using health and social care data.

The records are anonymised using a split-file approach; the demographic and clinical data are divided and sent to a trusted third party, Digital Health and Care Wales (DHCW) where a unique linking field is applied, removing any identifiers. This allows the files to be recombined later and for data to be linked across data sources. NCCH data were linked to primary and secondary care data sources and compared for babies born during the pandemic (2020) and children born before the pandemic (2016-19). Birth outcomes were stillbirths, gestational age at birth, rate of C-sections, and mortality. Covariates affecting outcomes and relating to possible pandemic differences included: residing in rural or urban areas and deprivation level. Data definitions for birth outcomes can be found in Appendix 1. Missing data was treated as missing except in the case of missing gestational age and, therefore, gestational age category (missing in 1327 [0.8%] cases). As the majority of the birth is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint weights in these cases were consistent with term weights, these were assigned as 40-weeks gestation and 'term' category respectively.

Descriptive statistics were used to calculate comparative outcomes of annual and monthly incidence of infant characteristics. Comparison was made between births in 2020, and the reference population (birth 2016-2019). Birth outcomes evaluated were stillbirths, gestational age at birth, birth weight, rate of C-sections, and mortality.

Odds and odds ratios (OR) were also calculated to compare pre-pandemic outcomes with 2020, using unconditional maximum likelihood estimations. Comparisons of routine childhood immunisations [49, 50, 51] were made between 2019 and 2020 for doses due at 8-, 12-and 16-weeks chronological age to examine if COVID measures impacted on vaccine uptake rates. No immunisations analysis of data prior to 2019 was undertaken because of variation of their codes over time.

There were some inconsistencies around dates in which immunisations were administered. As all babies have received all recommended immunisations, if one immunisation was administered on time, it was assumed all immunisations due at the same time were also given at that time.

Immunisations were considered 'on time' if given within 28-days of their due date. Second and third doses were on time if administered at 28-and 56-days respectively of the first dose these doses were also allowed to be up to 28-days after these dates. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint Information about the software used for cohort selection and analysis can be found in Appendix 2.

The linked data aspects of the study was approved by the SAIL Databank independent Information Governance Review Panel (project number 0916, Wales Electronic Cohort for Children Phase 4). The qualitative and survey aspects of the study were approved by HRA and Health and Care Research Wales (HCRW) REC reference: 21/NW/0156.

There were 159,620 births in Wales between 2016 and the end of 2020, with 263 removed during data cleaning due to inaccurate values for birth weight and/or gestation at birth. The remaining 159,357 babies were born to 141,679 women. 2020 saw fewer births than the previous average (29, 031 in 2020 compared to an average of 32,582 in previous years). The population characteristics can be seen in Table 2 . There was no significant difference between annual outcomes including gestation and birth weight, still birth, rates of C-section for infants born in 2020 compared to previous years. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Although there was no evidence of an increase in preterm births, for infants that were born preterm, there appears to be a small increase in preterm mortality (see Table 2 ). However, this appears to be a temporal slow increase year on year rather than associated with an increase only in 2020 (see figure 1 ).

The results suggest that during 2020, C-sections were more likely to be recorded in the routine data without indication of whether they were emergency or elective C-sections. This appears to have mostly affected the emergency C-sections.

There was a very small increase in high birth weight infants born in 2020 with an odd ratio of 1.04 (95%CI: 0.99-1.08, p=009). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint Routine Immunisations:

Uptake of the first three immunisations in the childhood schedule was 100% in both 2019 and 2020.

Immunisations in 2020 were less likely to be given on time at 8-and 16-weeks than in 2019 (8% and 19% lower respectively). At 12-weeks the number of immunisations given on time increased to 100% in 2020 (an increase of 8%), see Table 3 and Figure 4 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint

The survey received 215 responses between 7 th September 2020 and 1 st April 2021. Of the respondents, 203 (94%) were from a white ethnic background and average age was 32 years. 45% of expectant mothers responded 'yes' to whether they had periods of bad stress or stressful life events during their pregnancy (N=96). They were asked on a scale of 0 to 10, how stressful was this time (0 is not at all, 10 is overwhelming). The mean score was 7.43. 26% (N=26) said this stressful event was related to coronavirus. 25% (N=24) had someone close with a serious illness. 19% (N=18) experienced serious relationship difficulties with their husband or partner.

During this time 69% (N=66) had someone who could support them emotional or financially.

Expectant mothers who had periods of stress during their pregnancy reported higher anxiety levels than those who had no periods of stress. 84% of expectant mothers who had experienced periods of stress reported feeling nervous, anxious or on edge from several days a week to nearly every day compared to 48% of mothers who reported no stress. This anxiety was experienced 'not at all' by 52% of mothers who reported no periods of stress, compared to only 12% of mothers who had periods of stress.

Three key themes were developed from the qualitative data: (1) Perception of the severity of the COVID-19 pandemic, (2) difference to regular appointments and delivery and (3) support from midwives. A coding framework detailing the themes, subthemes and definitions is provided in Table/Appendix 1. Some expectant mothers described their experiences of pregnancy during the COVID-19 pandemic in positive terms, such as 'good', 'great' or 'excellent', and reported that they felt 'happy', 'calm', 'excited' or 'ecstatic'. However, 71% of expectant mothers described their experiences as being 'poor', 'awful' or 'terrible', and reported feeling 'stressed', 'uncertain', 'uninformed', 'isolated', 'anxious' and 'overwhelmed'.

Others still reported mixed feelings, stating that they were both happy to be pregnant yet anxious about the impact of COVID-19 and associated restrictions on their health and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint wellbeing and that of their unborn baby. In terms of perception of the pandemic, respondents reported changing their behaviour (e.g. avoiding the shops) and feeling nervous about catching COVID-19 and the potential lack of social support for them and their baby (see table 1 ). In terms of care, women worried about the health of their baby. They reported that they were offered virtual or telephone midwifery appointments and that support groups had moved online, however these were described as impersonal and women felt that these were less supportive than face-to-face visits. The main difficulty was in attending appointments and scans alone and the negative impact on their mental health of being unable to have their partner with them, especially during labour (see Table 1 ). In terms of midwife support, some expectant mothers were extremely positive about the support they received from their midwife, however, many reported that the support they had received was minimal and this was the same for both mothers having their first baby and those who already had children. The level of support received was cited by participants as a key factor that influenced whether or not they had a positive experience of pregnancy. Some women reported feeling very alone during their pregnancy, including some who felt they had received good support from their midwife. Women reported that communication issues with midwives had taken some of the joy out of their pregnancy and that they felt 'left in the dark' and unsure of their options or how to find out key information. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Difference to regular appointments and delivery Opinions on virtual appointments and services "I'm upset that I've missed out on face to face antenatal and breastfeeding classes (online classes are not the same)". Respondent 155 "Due to COVID-19 a telephone appointment was given, which feels very impersonal and not reassuring". Respondent 1

"All of the restrictions have made things a lot harder and the lack of support at appointments and scans has been extremely difficult". Respondent 82 "My partner couldn't be with me for my scans which had an impact on both of us and our mental health". Respondent 39 "I feel extremely worried about being in labour without my partner. The worry is dominating the pregnancy". Respondent 191 "Knowing I will be admitted into hospital away from my support system is crippling me with anxiety and knowing the father cannot visit the ward after to help through the day time is worrying me for their bonding could be affected and delayed". Respondent 4

Level of contact and support received from midwives and impact on mental health and enjoyment of pregnancy "Midwife has been absolutely outstanding". Respondent 205 "Having good support from the midwife and mental health team has made a difference to how I feel about being pregnant". Respondent 125 "I don't feel I've had any support from midwives as up until I was 28 weeks pregnant I had only seen a midwife very briefly once". Respondent 194 "I have had no support from the midwives, I am not even sure who my midwife is". Respondent 72 "I haven't been able to see a midwife at all. I have had two phone calls and that's it...support has been non-existent". Respondent 12 "I haven't enjoyed my pregnancy as much a much as previous pregnancies. Midwife support has been fantastic but still feel very much alone". Respondent 2 "Midwife support has been good but I feel lonely due to not having my partner involved much". Respondent 11 Communication issues . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint "I have only met my midwife once. I have questions and concerns but no one has returned my questions or called me back. I feel very let down as I know this is not the case for expectant mothers in other trusts who have had regular contact and support from their service providers". Respondent 153 "When I have seen midwives their care has been great but I do feel there has been a lack of support & communication in general. Appointments have been cancelled, lacking communication about processes and updates. I feel my experience of being pregnant first time has been dampened & I haven't experienced it as I should which has led to more anxiety and less excitement". Respondent 90 "It feels very different to my previous pregnancy. Less contact has meant I feel less informed and less sure of my options". Respondent 52 "I was told one of my samples was going to the lab and haven't heard anything since and don't even know where I would go to receive that information". Respondent 72 "I've had to put in the work to gain context and seek guidance on the internet". Respondent 177

This study found that experiencing pregnancy during the COVID-19 pandemic was stressful and difficult for the majority of the survey respondents. Expectant mothers described high levels of stress and anxiety. These results are in line with other recent studies reporting elevated stress and anxiety symptoms in pregnant women during the COVID-19 pandemic [26, 27] .

From the survey responses, many expectant mothers described themselves as anxious in 2020 with the additional stress of the pandemic during their pregnancy. However, this did not translate to higher population levels of adverse events in babies. Our observational study found that although premature births were not more prevalent for the year 2020, there is evidence that they may have been higher in the first lockdown (in April) in rural areas. In addition, the findings suggest that late term births may have been more prevalent in the first lockdown in June/July. Mortality among preterm infants was higher in 2020 but this seems part of a temporal trend of year on year rising mortality rates. This finding is likely related to increased interventions in preterm births and thus recording them as live births rather than stillbirths [52] ; rather than any effect of 2020 lockdown. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08. 23.21262209 doi: medRxiv preprint Primary immunisations due at 8-, 12-, and 16-weeks of chronological age were still given to 100% of babies born in 2020. This suggests that the pandemic may have not made mothers more reluctant to have their infants immunised as a result of pandemic activity. Differences in the proportions of babies receiving their immunisation on time may be due to changes in the maternity and health visitor services because of the pandemic. However, Figure 4 demonstrates that, in most cases, the variation is timing of doses is largely similar between 2019 and 2020.

A study that also adopted an online survey to explore socially distanced maternity care found similar results with negative consequences of pregnancy during the pandemic including distress and emotional trauma [53] . The messaging is that pregnancy during a pandemic is a unique experience and evidence-based approaches to providing care for expectant mothers during a pandemic should be prioritised [53] . It is stressed that maternity services should establish that the provision of safe face-to-face care and access for partners or familial support are encouraged.

This study is hypothesis generating and findings will need to be confirmed by comparison with other populations and data sources such as those in the UK (England, Northern Ireland and Scotland). The authors acknowledge that the responses from participants to the online survey will be biased towards those who had access to the internet as we could not conduct face to face recruitment. The authors also recognise that there may be bias where those who were having more negative experiences were more likely to take part in the online survey, therefore overestimating the prevalence of negative experiences or equally those who were extremely is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint from areas of deprivation and those from non-deprived areas. There was consensus early in the study with a majority reporting a negative experience of pregnancy in lockdown.

Our findings in the population are consistent with existing similar studies, which find no clear signal that babies born during the pandemic were adversely affected. However, changes to maternity and neonatal care, as well as the direct impact of COVID-19 was different across Wales, the UK and Europe, and regional variations and impacts have been reported.

One London hospital reported a higher incidence of stillbirths during the pandemic period compared with a pre-pandemic period but no differences in births before 37-weeks gestation or caesarean delivery [30] . In contrast, a study examining national and regional data from across England found no evidence of any increase in stillbirths during the COVID-19 pandemic compared with the same period in the previous year [31] . Studies from Ireland [32] , Denmark [33] and the Netherlands [34] have reported a decrease in the rate of premature births during lockdown, while a recent systematic review and meta-analysis reported: increases in stillbirth; no change in preterm births before 37-weeks gestation overall; a decrease in preterm births before 37 weeks in high-income countries; and no differences in modes of delivery, low birthweight or neonatal death [35] .

The association with later term births is interesting and warrants further investigation but despite the wide-ranging changes to maternity and neonatal care that occurred during the first few months of the pandemic in Wales, the lack of measurable impact on perinatal outcomes is striking, and contrasts with broad concerns raised at the time.

In conclusion, the pandemic had a negative impact on mothers' experiences of pregnancy; however, using population-scale national data, there was little evidence that this led in general to adverse pregnancy outcomes. Lockdown periods were associated with variations in preterm (lower rates in second lockdown) and slightly higher post term births in first lockdown. There is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint was no evidence that childhood immunisations uptake was lower due to lockdown measures.

Further analysis in the first year of life will be needed to examine if stress in pregnancy has longer-term consequences for the infant and their family.

This study is part the National Centre for Population Health and Wellbeing, which is funded is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted August 23, 2021. ; https://doi.org/10.1101/2021.08.23.21262209 doi: medRxiv preprint

Psychosocial stress during pregnancy

Anxiety Disorders During Pregnancy and the Postpartum Period

Prevalence and identification of anxiety disorders in pregnancy: the diagnostic accuracy of the two-item Generalised Anxiety Disorder scale (GAD-2)

The prevalence and determinants of pregnancy-related anxiety amongst pregnant women at less than 24 weeks of pregnancy in Bangalore, Southern India</p>

Pmb-Huca G. Incidence, prevalence and risk factors related to anxiety symptoms during pregnancy

Prevalence of pregnancy anxiety and associated factors

Stress Processes, Biopsychosocial Models, and Emerging Research Issues

The effects of maternal depression, anxiety, and perceived stress during pregnancy on preterm birth: A systematic review

Maternal Anxiety During Pregnancy and the Association With Adverse Perinatal Outcomes

Psychosocial stress during pregnancy is related to adverse birth outcomes: results from a large multi-ethnic community-based birth cohort

Neurodevelopmental outcomes at age 5 among children born preterm: EPIPAGE-2 cohort study

Respiratory complications of preterm birth

All-Cause Mortality of Low Birthweight Infants in Infancy, Childhood, and Adolescence: Population Study of England and Wales

The Contribution of Preterm Birth to Infant Mortality Rates in the United States

Psychological stress during pregnancy and stillbirth: prospective study

Prenatal maternal stress is associated with delivery analgesia and unplanned cesareans

Do stress and anxiety in early pregnancy affect the progress of labor: Evidence from the Wirral Child Health and Development Study

Epub ahead of print

Obstetric complications and anxiety during pregnancy: is there a relationship?

Possible relationship between general and pregnancy-related anxiety during the first half of pregnancy and the birth process: a prospective cohort study

WHO Declares COVID-19 a Pandemic

Hospital visiting during the coronavirus outbreak: guidance How the NHS can support hospital visiting in a safe and planned way during the coronavirus pandemic

for PregCOV-19 Living Systematic Review Consortium. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis

Public Health Wales Health Protection. Rapid COVID-19 surveillance

Saving lives, improving morthers' care rapid report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK

Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic

Mental health of pregnant women during the COVID-19 pandemic: A longitudinal study

Pandemic-related pregnancy stress and anxiety among women pregnant during the coronavirus disease 2019 pandemic

Stress and Anxiety Levels in Pregnant and Post-Partum Women during the COVID-19 Pandemic

Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic

Epub ahead of print

Stillbirths During the COVID-19 Pandemic in England

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

Danish premature birth rates during the COVID-19 lockdown

Impact of COVID-19 mitigation measures on the incidence of preterm birth: a national quasiexperimental study

Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health

Women's perceptions of COVID-19 and their healthcare experiences: a qualitative thematic analysis of a national survey of pregnant women in the United Kingdom

The lived experiences of pregnant women during COVID-19 pandemic: a descriptive phenomenological study

Correlates of experiencing life events just before or during pregnancy

The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener

A brief measure for assessing generalized anxiety disorder: the GAD-7

Reflecting on reflexive thematic analysis

Using thematic analysis in psychology

One size fits all? What counts as quality practice within (reflexive) thematic analysis? Qualitative Research in Psychology

Residential Anonymous Linking Fields (RALFs): a novel information infrastructure to study the interaction between the environment and individuals' health

The SAIL databank: linking multiple health and social care datasets

The SAIL Databank: building a national architecture for ehealth research and evaluation

A case study of the Secure Anonymous Information Linkage (SAIL) Gateway: a privacy protecting remote access system for health related research and evaluation

Understanding and responding to COVID-19 in Wales: protocol for a privacy-protecting data platform for enhanced epidemiology and evaluation of interventions

The Complete Routine Immunisation Schedule from

Routine Immunisation Schedule Wales from

Routine Childhood Immunisations from

Variability in the management and outcomes of extremely preterm births across five European countries: a population-based cohort study

Anxious and traumatised": users' experiences of maternity care in the UK during the COVID-19 pandemic