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Changes in obstetrical practices during the 2020 COVID-19 pandemic

      OBJECTIVE

      The COVID-19 pandemic disrupted almost every aspect of healthcare in the United States. Here, we take advantage of an ongoing investigation of practice patterns in the wake of the “A Randomized Trial of Induction Versus Expectant Management” (ARRIVE trial)
      • Grobman WA
      • Rice MM
      • Reddy UM
      • et al.
      Labor induction versus expectant management in low-risk nulliparous women.
      to determine if the COVID-19 pandemic was associated with a change in the trends we previously reported. Before the pandemic, there was an upward trend in 39-week labor inductions among low-risk, nulliparous patient populations.
      • Gilroy LC
      • Al-Kouatly HB
      • Minkoff HL
      • McLaren RA.
      Changes in obstetrical practices and pregnancy outcomes following the ARRIVE trial.
      In this report, we sought to determine if that trend was affected by the pandemic.

      STUDY DESIGN

      This was an institutional review board-exempt, population-based study of low-risk nulliparous deliveries occurring between 39+0 and 42+6 weeks. The US natality data from 2020 were released subsequent to our initial analysis.

      Natality information. Available at: https://wonder.cdc.gov/natality.html. Accessed March 2, 2022.

      Similar to our previous publication, obstetrical practice (induction, deliveries from 39+0 to 39+6 weeks, and cesarean delivery) in the pre-ARRIVE group (births between 2015 and 2017) was compared with that in the post-ARRIVE group (births in 2019, “2019 and now 2020” 2020). Multivariate logistic regression was used to adjust for confounders. We also focused on obstetrical practice rates by month during 2020 to determine how the initial surge and consequent lockdown affected trends.

      RESULTS

      There were 589,300 more 39+0 to 42+6 week deliveries added in 2020. Significant demographic differences between the pre- and post-ARRIVE groups remained after incorporating the 2020 data.
      • Gilroy LC
      • Al-Kouatly HB
      • Minkoff HL
      • McLaren RA.
      Changes in obstetrical practices and pregnancy outcomes following the ARRIVE trial.
      After adjusting for these differences, patients in the post-ARRIVE group were again, as reported in our previous cohort, more likely to undergo labor induction (37.4% vs 30.2%; adjusted odds ratio [aOR], 1.43 [1.42–1.43]), more likely to be delivered by 39+6 weeks (43.2% vs 39.9%; aOR, 1.17 [1.16–1.18]), and less likely to undergo cesarean delivery (27.3% vs 27.9%; aOR, 0.93 [0.93–0.94]).
      Of particular interest, in 2020, there was a 6-month pause in the upward trend of labor induction starting in May, followed by a recovery and then a further increase (from 38.5%– 40.1%) in December, resulting in a higher overall end-of-year rate. Deliveries by 39+6 weeks decreased in May (to 42.7%) but rebounded to a rate higher than the prepandemic rate (44.7%) by December (Figure). The overall cesarean delivery rate increased by 0.1 percentage point from 2019 to 2020, ending the year at 27.7%.
      Figure
      FigureMonth-by-month deliveries between 39+0 to 39+6 gestational weeks in 2020
      Gilroy. Changes in obstetrical practices during the COVID-19 pandemic. Am J Obstet Gynecol MFM 2022.
      US, United States.

      CONCLUSION

      There were further overall increases in labor induction and 39th week deliveries among low-risk nulliparous pregnant patients in 2020. However, from May to November, there was a noticeable dip in 39th week deliveries, with a plateau in labor induction during this interval, suggesting an effect of the pandemic on the patterns of practice. The data raise the question of why the 39th week births did not plateau when the induction rates did. One theoretical possibility is that spontaneous births in the 39th week declined owing to sheltering, stress, or an unknown factor that could have delayed the onset of labor. Although the cesarean delivery rate remained lower in the post-ARRIVE group after including the 2020 data, the month-by-month rates in 2020 showed an increased rate by the end of the year. It is difficult to correlate specific spikes or lows in these 2020 practice rates with “waves” of the COVID-19 pandemic, given that periods of high disease prevalence affected US geographic regions at different time periods.
      • Oster AM
      • Kang GJ
      • Cha AE
      • et al.
      Trends in number and distribution of COVID-19 hotspot counties – United States, March 8–July 15, 2020.
      Furthermore, lockdown timing and adherence differed greatly by state in the United States, making nationwide data more difficult to interpret. A lthough the overall rates of these practices in 2020 are consistent with the trend established in 2019, reflecting a potentially continued influence of the ARRIVE trial on obstetrical practices in the United States, an apparent, albeit transitory effect of the COVID-19 pandemic was observed.

      Appendix. Supplementary materials

      References

        • Grobman WA
        • Rice MM
        • Reddy UM
        • et al.
        Labor induction versus expectant management in low-risk nulliparous women.
        N Engl J Med. 2018; 379: 513-523
        • Gilroy LC
        • Al-Kouatly HB
        • Minkoff HL
        • McLaren RA.
        Changes in obstetrical practices and pregnancy outcomes following the ARRIVE trial.
        Am J Obstet Gynecol. 2022; 226 (716.e1–12)
      1. Natality information. Available at: https://wonder.cdc.gov/natality.html. Accessed March 2, 2022.

        • Oster AM
        • Kang GJ
        • Cha AE
        • et al.
        Trends in number and distribution of COVID-19 hotspot counties – United States, March 8–July 15, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 1127-1132