Research Letter | Obstetrics and Gynecology

Perinatal Outcomes During the COVID-19 Pandemic in Ontario, Canada

Andrea N. Simpson, MD, MSc; John W. Snelgrove, MD, MSc; Rinku Sutradhar, PhD; Karl Everett, MSc; Ning Liu, PhD; Nancy N. Baxter, MD, PhD

Introduction + Supplemental content

Public health measures to control the COVID-19 pandemic may be associated with reduced risk of Author affiliations and article information are
1,2 listed at the end of this article.
preterm birth (PTB). Conversely, avoidance of health care may be associated with increased risk of
stillbirth.3 We evaluated rates of PTB and stillbirth during the first 6 months of the pandemic because
previous studies conducted early in the pandemic have had inconsistent results.

Methods
We performed a population-based cohort study in Ontario, Canada, using linked databases at ICES
(formerly Institute for Clinical Evaluative Sciences).4 Data use without consent is authorized under
section 45 of Ontario’s Personal Health Information Protection Act; thus, review by a research ethics
board was not required. We followed the Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) reporting in epidemiology guideline.5
In-hospital births at 20 weeks’ or more gestational age (GA) from March 15 to September 30,
2020 (pandemic group), were compared with corresponding calendar periods from 2015 to 2019
(historical group) (eFigure in the Supplement). Births were identified in the Mother-Baby Data Set
derived from the Canadian Institute for Health Information Discharge Abstract Database. Maternal
characteristics included age, parity, singleton vs multiple gestation, area-level income quintile,
comorbidities, pregnancy conceived with assisted reproductive technology, and SARS-CoV-2
infection during pregnancy.
PTB (live birth at <37 weeks’ GA) and stillbirths (intrauterine death at ⱖ20 weeks’ GA) were the
primary outcomes. Secondary outcomes were extreme PTB (<28 weeks’ GA), very PTB (<32 weeks’
GA), severe small for GA (birth weight less than the fifth percentile for sex and GA), neonatal
intensive care unit admission, and early (up to 7 days) and late (8-28 days) neonatal death.
We used univariable and multivariable logistic regression models to examine the association
between birth period (pandemic vs historical) and odds of each outcome. A generalized estimating
equations approach was used to account for clustering at the level of birth institution. We assessed

Table. Multivariable Generalized Estimating Equation Logistic Regression Analyses to Determine the Odds
of Adverse Perinatal Outcomes During the Pandemic Period Compared With the Historical Period
Abbreviations: GA, gestational age; OR, odds ratio.
Births, No. (%) OR (95% CI)
a
Adjusted analysis included the following variables:
Pandemic group Historical group
Outcome (n = 67 747) (n = 348 633) Unadjusted Adjusteda maternal age at index birth (continuous), parity
Preterm birth (<37 wk GA) 5103 (7.5) 26 216 (7.5) 1.00 (0.95-1.04) 0.99 (0.97-1.03) (number of births ⱖ20 weeks’ GA, continuous),
singleton vs multiple birth (binary), Aggregated
Stillbirth 347 (0.5) 1799 (0.5) 0.99 (0.89-1.11) 0.99 (0.89-1.11)
Diagnosis Groups score (continuous), income
Extreme preterm birth (<28 wk GA) 406 (0.6) 2254 (0.6) 0.90 (0.78-1.04) 0.91 (0.80-1.03) quintile (categorical, with 1 as the lowest and 5 as the
Very preterm birth (<32 wk GA) 807 (1.2) 4531 (1.3) 0.89 (0.80-0.99)b 0.91 (0.85-0.98)b highest), rural residence (binary, urban vs rural),
Severe small for GA 3826 (5.6) 19 225 (5.5) 1.02 (0.98-1.07) 1.02 (0.98-1.08) preexisting hypertension (binary), preexisting
diabetes (binary), pregnancy conceived with assisted
Neonatal intensive care unit 8526 (12.6) 43 049 (12.3) 1.01 (0.93-1.10) 1.01 (0.94-1.08)
admission reproductive technology (binary), short interbirth
Neonatal death interval (<18 months, binary), and history of preterm
birth (binary).
Early 83 (0.1) 539 (0.2) 0.75 (0.50-1.14) 0.77 (0.51-1.15)
b
Denotes significance. Observations with missing
Late 30 (0.0) 165 (0.0) 0.91 (0.52-1.60) 0.96 (0.61-1.51)
variables were excluded from the model.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Obstetrics and Gynecology Perinatal Outcomes During the COVID-19 Pandemic in Ontario, Canada

the effect of time spent in the pandemic by incorporating an interaction term between our exposure
(pandemic vs historical birth) and number of weeks since March 15, 2020, for each PTB outcome.
Analyses were performed using SAS Enterprise Guide statistical software version 7.15 (SAS Institute).
Statistical tests were 2-sided, with α < .05 considered significant. Data analysis was performed from
March 15 to September 30, 2020.

Results
A total of 67 747 births occurred during the pandemic period, and 348 633 births occurred during the
historical period. There were no differences in baseline characteristics between groups. There was
no difference in the proportion of PTBs (5103 [7.5%] vs 26 216 [7.5%] PTBs) or stillbirths (347 [0.5%]
vs 1799 [0.5%] stillbirths) between the pandemic and historical groups. After multivariable analysis,
the adjusted odds ratio (aOR) for PTB was 1.00 (95% CI, 0.97-1.03), and that for stillbirth was 0.99
(95% CI, 0.89-1.11) (Table). We observed a small but significant difference in very PTB (<32 weeks’
GA) in the 2 groups (4531 [1.3%] vs 807 [1.2%] very PTBs; OR, 0.89; 95% CI, 0.80-0.99), which
persisted after multivariable adjustment (aOR, 0.91; 95% CI, 0.85-0.98). There were no differences
in extreme PTB, severe small for GA, neonatal intensive care unit admission, or neonatal death. We
found no significant association between time spent in the pandemic and any outcome.

Discussion
We found no differences in the overall risk of PTB, stillbirth, or other perinatal outcomes during the
first 6 months of the COVID-19 pandemic. We observed a small reduction in PTB at less than 32
weeks’ GA, similar to Denmark and Ireland, where comparable strict lockdown measures were in
effect.1,2 In contrast, no difference in PTB was observed in a population-based study in Sweden,
where strict lockdown orders were not in effect.6
Limitations of this study include the inability to evaluate out-of-hospital births; however, less
than 3% of births in Ontario occur outside of hospitals. We could not evaluate for some factors that
influence PTB risk, such as smoking. We did not evaluate the risk of PTB among women who
experienced COVID-19 during pregnancy because this number was small.
The COVID-19 pandemic first wave did not coincide with significant changes in overall PTB or
stillbirth in Ontario. A small reduction in PTB at less than 32 weeks’ GA suggests that strict lockdown
measures may have been associated with reduced risk in this subgroup.

ARTICLE INFORMATION
Accepted for Publication: March 19, 2021.
Published: May 12, 2021. doi:10.1001/jamanetworkopen.2021.10104
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Simpson AN
et al. JAMA Network Open.
Corresponding Author: Andrea N. Simpson, MD, MSc, Department of Obstetrics and Gynaecology, St Michael’s
Hospital, Unity Health Toronto, 61 Queen St E, 5th Flr, Toronto, ON M5C 2T2, Canada (andrea.simpon@
unityhealth.to).
Author Affiliations: Department of Obstetrics and Gynaecology, St Michael’s Hospital, Unity Health Toronto,
Toronto, Ontario, Canada (Simpson); Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario,
Canada (Simpson, Baxter); ICES, Toronto, Ontario, Canada (Simpson, Sutradhar, Everett, Liu, Baxter); Department
of Obstetrics and Gynaecology, Sinai Health System, Toronto, Ontario, Canada (Snelgrove); Dalla Lana School of
Public Health, Division of Biostatistics, University of Toronto, Toronto, Ontario, Canada (Sutradhar); Institute of
Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (Liu); Department of
Surgery, University of Toronto, Toronto, Ontario, Canada (Baxter); Melbourne School of Population and Global
Health, University of Melbourne, Melbourne, Victoria, Australia (Baxter).

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 JAMA Network Open | Obstetrics and Gynecology Perinatal Outcomes During the COVID-19 Pandemic in Ontario, Canada

Author Contributions: Dr Simpson had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Simpson, Snelgrove, Sutradhar.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Simpson, Sutradhar.
Critical revision of the manuscript for important intellectual content: Snelgrove, Sutradhar, Everett, Liu, Baxter.
Statistical analysis: All authors.
Obtained funding: Simpson, Baxter.
Administrative, technical, or material support: Simpson, Baxter.
Supervision: Sutradhar, Baxter.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by ICES, which is funded by an annual grant from the Ontario
Ministry of Health and Long-Term Care (MOHLTC). This study was conducted with grant funding from the John R.
McArthur Endowment Research Grant, Department of Obstetrics and Gynaecology, University of Toronto, and
from the Department of Obstetrics and Gynaecology, St Michael’s Hospital (start-up grant to Dr Simpson).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Disclaimers: The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors
and do not reflect those of the funding or data sources; no endorsement by ICES or the MOHLTC is intended or
should be inferred. Parts of this material are based on data and information compiled and provided by the
Canadian Institute for Health Information and Ministry of Health & Long-Term Care. However, the conclusions,
opinions, and statements expressed herein are solely those of the authors, and not of those bodies listed. No
endorsement by these bodies is intended or should be inferred.
Additional Information: The data set from this study is held securely in coded form at ICES. Although data sharing
agreements prohibit ICES from making the data set publicly available, access may be granted to those who meet
prespecified criteria for confidential access (http://www.ices.on.ca/DAS).

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SUPPLEMENT.
eFigure. Flow Diagram of Included Births in the Historical and Pandemic Groups

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