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.