Discussion
In this study of the current COVID-19 pandemic versus the parallel
period in the previous year, we report a similar rate of ED referrals
and deliveries, and similar delivery and perinatal outcomes.
Pregnant women traditionally deliver in hospitals. During pandemics, an
important area of concern is the implementation of infection control
practices in delivery units, with emphasis on the best practices to keep
healthy pregnant and postpartum women and newborns from being exposed to
infected individuals.10
Patients’ fear of seeking hospital-based care may be an important
determinant of hospital services utilization during a pandemic
outbreak.11 Thus, a hospital’s level of preparedness
for pandemics may play a central role in a woman’s decision to attend
it.
The first COVID-19 confirmed infection in Israel occurred in February
27. However, Sheba Medical Center was the first Israeli hospital to
construct a specifically designated, geographically isolated complex for
COVID-19-exposed patients, more than two weeks prior to the first
confirmed infection. On February 20, the first Israeli persons exposed
to COVID-19 were hospitalized in this complex. Subsequently, our
department was the first department of obstetrics and gynecology in
Israel to construct a separate, designated complex for its
COVID-19-exposed patients. This complex was constructed to provide all
obstetrical and gynecological treatment and management facilities
including a fully equipped ED, delivery unit, operating rooms and
hospitalizations rooms. Women suspected with COVID-19 infection were
first identified at a triage ward at the department’s entrance. These
women were subsequently referred to the designated complex for further
treatment. The measures undertaken in our hospital, aimed at providing
optimal isolation and separation of healthy population and COVID-19
suspected persons, were widely reported over television broadcasts in
Israel.
Our results, indicating similar ED number of referrals between 2020 and
2019, suggest that the measures taken to provide isolation accessibility
at our hospital reassured the parturient population to attend it,
despite increasing restrictions on mobility imposed by the government.
The World Health Organization has advised to consider reducing prenatal
clinic visits to a minimum during the Pandemic Influenza
A.12 Concurrently, Turrentine et al have described a
drive-through prenatal care model to reduce the number of in-person
prenatal visits during the COVID-19 outbreak.13
Current data regarding hospital referrals rate during the COVID-19 from
other medical centers are still lacking. However, a study on the SARS
outbreak has found a significant decrease in the number of hospital
admission rate during this period.11 This is in
contrast with our results, but evidently does not represent exactly the
same population.
We did observe a decrease in the number of referrals in the final week
of the study period, probably due to further enforcement of lockdown.
This finding is in line with the observation that a higher proportion of
women were admitted to the delivery unit and a lower proportion of women
were discharged home in the final weeks of the period, and to the
decreased time spent in the ED during the final week of the period.
We did not observe a significant difference in delivery or neonatal
outcomes between the 2020 and 2019 periods, and on a week per week
stratification. This is an important point to underline, as burnout and
exhaustion of obstetrical staff imposed by physical strain of personal
protection equipment, physical isolation and long shift hours might
impact medical staff and result in decreased relational skills, an
impairment of empathic skills and a negative or hasty approach.14,15. However, the radical shift in working practice
characteristics during the outbreak did not result in a difference in
obstetrical outcome.
Following professional recommendations and guidelines to reduce elective
and ambulatory antenatal care to minimum15,16, during
the study period in 2020, the hospital’s ambulatory activity was
decreased to a minimum, and medical staff was allocated to provide care
for urgent cases. Nevertheless, as our results demonstrate, we have
managed to keep our obstetrical care in routine standard.
Our study is not without limitations. Its comparison to retrospective
data from the previous year may increase the risk of bias inherent to
such investigations. Second, we could not obtain data of referrals’ rate
from other medical centers in our area, limiting our ability to infer
conclusions from our number of ED referrals. Third, the limited period
of time evaluated in our study might underrepresent the actual impact of
the current outbreak on obstetrical care in our center.
The main strength of our study is the relatively large cohort of
patients and deliveries in a short period. Second, the meticulous data
collection and the stratification of the period to weeks allowed
optimization of our study results.
In conclusion, with timely preparation and proper management, negative
impact of the COVID-19 outbreak on obstetrical emergency departments and
delivery units can be reduced. Our results can aid in better decision
management in the current and future infection outbreaks.
Acknowledgements: None.
Disclosure statement: The authors declare that they have no
conflicts of interest.