EFFECT ON MODE OF CHILD BIRTH AND ITS OUTCOMES BEFORE AND DURING THE COVID-19 PANDEMIC AT ILAM DISTRICT HOSPITAL: A COMPARATIVE DESCRIPTIVE CROSS-SECTIONAL STUDY

duraon that includes one year period from nd nd 22 October 2019 to 22 march 2020 (before pandemic) and from rd rd 23 March 2020 to 23 September 2020 (pandemic duraon) at Ilam District Hospital. All the informaon used in this research was taken from Health Management Informaon System (HMIS) log book. The permission to use the recorded data was obtained from the hospital. Anonymity and conﬁdenality of data were maintained and no personal informaon was used in this research to protect the identy of the paents. The data was collected from the HMIS records of the hospital and was then processed in Microso excel. The result shows despite the lockdown and pandemic the percentage of paents coming to receive delivery services within the hospital increased about 9% which is an exceponally good result. Emergency CS was found to be decreased by 3%. During the pandemic Hospital stay was signiﬁcantly reduced for paent's safety due to COVID-19. However, no adverse impact was observed on the health outcomes of the mother and baby due to a short stay at the hospital. and the number of parents This was possible due to proper management and pre-plan services according to the government's COVID-19 protocol to cope with the and demand of the health services as other nearby hospitals closed their door during the In the future, a short stay at the hospital can be connued to cope with a high the department we the both mother and has not been impacted due to short stay in the hospital during the pandemic. ABSTRACT


Introduc on
Nepal started full lockdown from 24 March to 14 June 2020, followed by par al lockdowns mul ple mes as a precau on for the preven on of COVID-19 infec on. Managing health care services was a major issue during the COVID-19 pandemic for both the pa ents and health care professionals including services targe ng pregnant women in developing countries like Nepal.

Objec ves
To study the impact of the COVID-19 pandemic on childbirth services a ended at a district government hospital and to observe the impact on mode of delivery and maternal-child health. Methodology This descrip ve cross-sec onal study aimed to find out the impact on delivery services during the pandemic compared to pre-pandemic dura on that includes one year period from nd nd 22 October 2019 to 22 march 2020 (before pandemic) and from rd rd 23 March 2020 to 23 September 2020 (pandemic dura on) at Ilam District Hospital. All the informa on used in this research was taken from Health Management Informa on System (HMIS) log book. The permission to use the recorded data was obtained from the hospital. Anonymity and confiden ality of data were maintained and no personal informa on was used in this research to protect the iden ty of the pa ents. The data was collected from the HMIS records of the hospital and was then processed in Microso excel.

Results
The result shows despite the lockdown and pandemic the percentage of pa ents coming to receive delivery services within the hospital increased about 9% which is an excep onally good result. Emergency CS was found to be decreased by 3%. During the pandemic Hospital stay was significantly reduced for pa ent's safety due to COVID-19. However, no adverse impact was observed on the health outcomes of the mother and baby due to a short stay at the hospital.

INTRODUCTION
The health and wellbeing of women have been hugely impacted due to the pandemic, par cularly of the pregnant women who are facing several challenges to receive mely maternal health services from the hospital. This is mainly due to the lack of an adequate transporta on system, fear of transmission of the COVID-19 infec on. These challenges were highly amplified for those pregnant women who are living in rural/remote areas and for families with poor socioeconomic backgrounds. The low u liza on of maternal health services may become a barrier to good outcomes. Although there is a provision of free delivery as a policy implemented by the government of Nepal, pregnant women faced par cular challenges and barriers to access maternal health care services. Maternal health is an important aspect in women's life ranging from phase-wise ming of a endance at rou ne antenatal (pregnancy care visits, childbirth, and postnatal status) along with the availability of qualified health prac oners, staff, doctor 1,2 and hospital's infrastructure.
The world has faced an unprecedented public health crisis due to COVID-19. In Nepal,the first lockdown was imposed th th from 24 March 2020 to 14 June 2020, which was followed by several lockdowns of short periods as a precau on for the preven on o he spread of infec on. COVID-19 stretched the under-resourced health system of low-income and middle-income countries like Nepal, leading to a significant impact on the health system, socioeconomic and cultural structures, and widening healthcare access inequali es especially increasing the burden of adverse birth outcomes of pregnancies. During the pandemic period, the health care system became over-burdened and medical professionals were worried about obstetric quality care for maternal-child health and have the fear that caregivers, such as health 3,4 professionals might suffer.
The purpose of this study was to compare maternal health services especially hospital delivery services during one year period that included six months pre-pandemic and the first six months of the pandemic period. (before pandemic) and from23 March 2020 to 23 September 2020 (pandemic dura on). All the cases of study period were studied. This study was conducted based on the Helsinki declara on. Due to unavailability of ins tu onal review board at the hospital the permission to use the anonymous data was obtained from the hospital administra on and all the records of the pa ents visi ng the hospital for the delivery during that me were obtained from HMIS record and taken as sample size by convenient sampling and entered and processed in Microso Excel 2013. Personal details of pa ents have not been used in this research so that the anonymity of the pa ents can be maintained. The data were then subtracted and reanalyzed by using MS Excel. Descrip ve sta s cs as frequencies and percentages were used to analyze the data.

RESULT
During the total dura on of the study 1,218 deliveries were performed, out of which 582 (426 vaginal delivery and 156 cesarean sec on) were during the pre-COVID period. Meanwhile, 636 (474 vaginal deliveries and 162 cesarean sec ons) were during the first six months of the COVID period.   Most of the neonates weighted in the range of 2-3.9 kgs (468 in pre-COVID-19 and 546 in post-COVID-19 period). Most of the neonates had an APGAR score of more than 6.

DISCUSSION
During the lockdown period, at Ilam district hospital, only o n e s u rge o n wa s p e r fo r m i n g exa m i n a o n s l i ke ultrasonography along with pre and post-opera ve management for both mother and baby with the help of well-trained nurses and paramedics. During the pandemic, pa ents with a single visitor were allowed in the hospital with some restric ons followed by health protocols provided by the government. During the pandemic, antenatal care visits were disturbed due to lack of transporta on and fear of transmission of infec on from the hospital which was not favorable for the maternal and neonatal outcomes. At admission for delivery in the hospital, on-duty staff and the doctor recorded detailed history of age, parity, previous obstetric history, gesta onal age, whether referred from other centers (details of referral if the pa ent was referred), maternal general condi on, fetal posi on and presenta on, and heart sounds, pelvic assessment, state of liquor amnio c fluid and cervical 5,6 dila on along with any other danger signs and symptoms. Many factors influence the mode of delivery such as parity, gravidity, gesta on age, previous delivery, employment status, financial burden, mode of transporta on. Common modes of delivery are vaginal (unassisted i.e. natural, help with medicine or episiotomy, and assisted i.e. forceps or vacuum) and cesarean sec on by surgical interven on. The pregnant mother also expects choices in decision making, pain control, and social support. Pa ents and family members also have to plan about how to care during antepartum, partum and post-partum periods as any altera on in the plan may increase stress to pa ents and family members.
Restric ons in transporta on and disrupted health services resulted in a lack of scheduled ante-natal visits and a lack of proper and adequate inves ga ons impacted the family expecta ons. During this period, any complicated labor was referred to the ter ary level government hospital, for example, Koshi Hospital in coordina on with their doctors.
The primary responsibili es of nurses include the admission process, maternal/fetal assessment, and proper clinical care at the bedside. Experienced nursing staff and appropriate nurse-doctor communica on can make posi ve impacts on pa erns of delivery modes and outcomes. Care by an experienced nurse during labor can predict delivery mode during the intrapartum period and op mal nurse-doctor communica on has a role in decision making about the mode of delivery. Modes of delivery can be influenced by 7 nurses' knowledge of labor and doctors' prac ce pa erns.
In the community normal vaginal delivery is s ll be er for the mother and child while CS and opera ve vaginal deliveries are associated with risk and such deliveries mode should be only undertaken when indicated. Episiotomy is trauma to the perineum which needs surgical repair and some mes may have long-term consequences. The longterm consequences of OASIS (obstetric anal sphincter injuries)are much more serious and difficult to manage which requires well-trained and experienced manpower. Several intrapartum techniques as perineal massage and 8,9 warm perineal compress may reduce the risk of OASIS.
In low-income countries, CS may be higher due to delays in assessing referral health facili es. Common indica ons for CS include maternal condi ons(prolonged, obstructed labor, abrup on of placenta, hypertensive disorders) and fetal condi ons (cephalo-pelvic dispropor on, fetal 10 distress, and malpresenta on) to name a few. COVID-19 lockdown led to restric ons in transporta on except for emergency services and thus, reduced health care accessibility, especially for out-pa ent consulta ons due to which many pa ents failed to get rou ne antenatal checkups. Moreover, they also feared the transmission of disease in hospitals. Some studies showed an increase in 11,12 maternal mortality. During the early phase of the pandemic health care providers were also feeling anxiety, insomnia, and depression may be due to inadequate precau onary measures and lack of proper safety 13 equipment in the workplace. While maternity services access was limited within Nepal and around the world, it is a very interes ng and significant finding that despite the lockdown and pandemic the hospital provided a large number of delivery services in the maternity department, about a 9% increase compared to the pre-pandemic dura on. The reason could be women not finding a hospital to go to for maternity health services around the region because many hospitals stopped providing the services and there was a limited transport service. We have noted that day me delivery occurred very o en and increased about 10% during the pandemic. The possible explana on could be the arrival of pa ents in the morning hours with labor pain and the induc on process ini ated in the morning hours. This is not a significant outcome as we have noted the majority of the delivery occurred in the day me even in the pre-pandemic period. Interes ngly, the APGAR score at 5minutes during and before the pandemic was almost the same. That means despite huge constrained health services during the pandemic, properly planned services can have the same or posi ve impact on the health of the child. We have seen limited changes in the socio-demographic profile of women who used the delivery services at the hospital. Most of the mothers aged 21-30 years during both pre-COVID-19 (62.89%) and pandemic COVID-19 period (55.66%). Most of the women who a ended the hospital for the service were from the Ilam district. Social factors such as low educa on, limited access to health care, financial dependency and cultural norms can also put women in a lower posi on in society.COVID-19 impact on health care may be of long term and to avoid or improve health care health personnel should be trained to deal with such situa ons. Limited health care during this pandemic may have a great impact on the accessibility of health care 14 among women in poor countries. This may affect the mode of delivery and its outcome. Results from a published study of the same hospital during one year period included 1102 deliveries out of which vaginal delivery was 83.93% and CS 14.7%.; newborn birth weight between 2.5 to 3.9 kg 80.24%, APGAR of more than 6 in 97.53% of the newborn at 5 15 minutes; and CS(14.7%). In comparison to the above study,present results of 1218 deliveries in one year period included 582 pre-COVID and 636 deliveries in COVID period, the increase a ributed to lack of services in the periphery due to shut down; vaginal deliveries pre-COVID 73% was comparable to COVID period 74% was lower than previous study 83.9%, and CS pre-COVID 27% was similar to COVID period 26%. A slightly shorter dura on of hospital stay for vaginal and CS delivery during the COVID period was noted.

CONCLUSION
While maternity services have been significantly impacted during the pandemic within Nepal and around the world, Ilam hospital maintained its services for pregnant women and accepted a large number of admission at maternity units despite the shortage of staff and facili es. The hospital was prepared well to provide the services and to cope with the service demand during the pandemic. Study has concluded that there was no impact on the services at the maternity unit and health outcomes of mother and baby. It was also noted that the percentages of CS in this hospital was slightly lower during the pandemic compared to pre-pandemic records.

LIMITATION OF THE STUDY
Our study was single-centered and the sample size was small, so a larger sample size and mul -center study with longer follow-up are recommended.