A systematic review of maternal and perinatal health outcomes in the context of epidemic threats: towards the development of a core outcome set.

doi:10.21203/rs.3.rs-4607012/v1

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Systematic Review

A systematic review of maternal and perinatal health outcomes in the context of epidemic threats: towards the development of a core outcome set.

https://doi.org/10.21203/rs.3.rs-4607012/v1

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Objective

To systematically identify and classify maternal and perinatal health outcomes reported in research conducted in the epidemic and pandemic context.

Study design and Setting

We conducted a systematic review following Cochrane Methods. We searched MEDLINE, EMBASE, LILACS, SCI-EXPANDED, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO, AMED, ClinicalTrials.gov and ICTRP, between January 2015 and March 2023. Experimental, quasi-experimental, observational studies, phase IV trials, and post-marketing studies, published protocols and ongoing registered studies reporting maternal and perinatal health outcomes were included. Studies only reporting coverage of interventions, access to routine health services, clinical presentation of infectious diseases, and reviews were excluded. A sampling strategy was used for COVID-19 studies, due to their very high numbers. Outcome verbatims were extracted and categorized in unique outcome, and further classified into domains and subdomains. Frequency of outcome reporting was calculated.

Results

94 maternal and pregnancy and 47 unique neonatal outcomes were identified, from a total of 917 and 657 verbatims, respectively, reported across 440 included studies. At least 20% of included studies reported maternal and pregnancy outcomes of mode of delivery (56.1%), stillbirth (33.0%), preterm birth (28.6%), hypertensive disorders of pregnancy (26.6%), and maternal death (20.7%). These outcomes were identified across all three types of studies identified (epidemiological, product development or post-authorization surveillance). Gestational age at birth (29.8%), congenital malformations of the nervous system (26.1%), birth weight (23.4%), neonatal admission to intensive care unit (23.2%), and neonatal death (19.1%) were the most frequently reported neonatal outcomes.

Conclusions

Our study provides the basis for developing a core outcome set to measure maternal and perinatal health during outbreaks, which would help improve data collection of harmonized data, data synthesis, and timely development of informed public health guidance and clinical care responding to the needs of pregnant women. .

Obstetrics & Gynecology

Maternal & Fetal Medicine

Infectious Diseases

Epidemiology

Maternal

Pregnancy

newborn

epidemics

pandemic

systematic review

Inthe last decades, the world has witnessed a wave of outbreaks of infectious diseases with an epidemic and pandemic potential [1]. Pregnant and recently pregnant women, and their offspring (neonates, fetuses, and embryos), have often been negatively impacted by direct and indirect effects of outbreaks of respiratory diseases [2–5], zoonosis [6], and vector-borne diseases [7]. Outbreaks may directly increase the risk of severe maternal and perinatal morbidity or mortality [3–5, 7, 8]. In addition, decreased access to routine and emergency health services, and the social and economic burdens of outbreaks, indirectlyaffects the health and well-being of women and their offspring, particularly in resource-limited settings [6, 9, 10].

However, the process of generating relevant scientific evidence on effects of outbreaks, epidemics and pandemics on maternal and perinatal health generally lags behind [11, 12]. Wide variations in how health outcomes are defined, measured and reported across studies significantly limits researchers’ ability to compare and interpret findings and to draw reliable conclusions [13–15]. This, in turn, represents a substantial barrier to translating research into public health interventions and clinical practice. As a result, decision-makers, healthcare providers, pregnant women and their families lack the necessary information to make informed decisions on maternal and perinatal care [16].

Timely generation and use of evidence could be facilitated by a set of core outcomes for measuring maternal and perinatal health during outbreaks, epidemics or pandemics. A core outcome set represents a minimum dataset, developed following robust consensus methods, ideally informed by a systematic review, that should be used in clinical trials, or other types of studies pertaining to specific areas of research, for measuring and reporting health outcomes that are relevant to healthcare providers, service users, and others involved in the decision-making process [17].

Available literature presents a combination of systematic reviews and consensus-building processes used to harmonize pregnancy and child outcomes for monitoring safety of novel vaccines during pregnancy, mainly related to COVID-19 vaccination in low- and middle-income countries (LMICs) [18–23]. So far, no unified set of outcomes has been proposed for maternal and perinatal research conducted during emerging and ongoing epidemic threats. To be better prepared for the next epidemic threat, having a core set of outcomes for measuring maternal and perinatal health in all research studies is not only desirable, but also necessary [12].

This systematic review aims to identify and classify maternal and perinatal health outcomes reported in the scientific literature, in view of informing development of a core outcome set for maternal and perinatal health during epidemic threats.

We conducted a systematic review following Cochrane Methods [24]; and results have been reported complying the recommendations of PRISMA statement 2020 [25].The systematic review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the ID = CRD42023423196). The project was also registered in the Core Outcome Measures in Effectiveness Trials (COMET) initiative.

2.1 Inclusion and exclusion criteria

We included studies reporting any maternal and perinatal outcomes, including health outcomes (physical, psychological, efficacy/effectiveness, and safety outcomes pertaining to both therapeutic and preventive interventions, and obstetric/clinical management) of infected and non-infected pregnant women and their offspring (neonates, fetuses, and embryos). All study designs were considered for inclusion: experimental, quasi-experimental, comparative, or non-comparative observational studies, case series, phase IV trials, and post-marketing studies, with a sample size of at least 50 subjects. The same specifications were applied to published protocols and ongoing registered studies.

We excluded articles reporting only outcomes related to coverage and access to routine health services or process outcomes (e.g., number of prenatal visits), clinical presentation of symptomatic infectious diseases or risk factors of diseases. We also excluded literature reviews, systematic reviews, and overviews. Systematic reviews served mainly as sources of relevant primary studies.

2.2 Search strategy

The search strategy was developed by the review team and an experienced health sciences librarian. It covered the period between 01 January 2015 and 24 March 2023 and was performed using the following electronic databases: MEDLINE, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Science Citation Index Expanded (SCI-EXPANDED), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Central Register of Controlled Trials, PsycINFO, AMED, ClinicalTrials.gov website and International Clinical Trials Registry Platform (ICTRP). No language restrictions were applied. The full details of the search strategy can be found in Supplement A.

2.3 Selection of studies and data extraction

Pairs of review authors (FS, VO, CN, MBa) independently screened titles and abstracts yielded by the search and assessed them against the inclusion and exclusion criteria. After retrieving all potentially relevant full-text studies, the same pairs of review authors independently selected full texts and documented ineligible studies and the reasons for their exclusion. Disagreements were resolved through discussions among members of the review team. The entire process was performed using the web-based software COVIDENCE (Innovation VH. Covidence systematic review software. Melbourne, Australia; 2019).

A data extraction tool was developed, considering a wide diversity of outcomes to be explored, and used to extract data from the selected full-text articles. The data extraction tool was piloted using a sample of ten studies and refined further during the extraction process. The abovementioned pairs of review authors independently extracted all included studies. Any disagreements on data extraction were resolved by consensus among the members of the review team.

Each study was assigned its unique identification number and the following information was extracted: first author, year of publication, sample size of pregnant, non-pregnant and neonatal population, study period, geographical coverage (countries covered, region), type of study (epidemiological/burden of disease, product development or post-authorization surveillance), infectious disease, mode of transmission (respiratory [COVID-19 and influenza], hemorrhagic fever zoonosis [Ebola and Rift Valley fever], foodborne/waterborne [cholera], and vector-borne [zika, chikungunya, dengue, yellow fever]), and type of outcome (maternal and pregnancy, including outcomes related to childbirth and postnatal care, and neonatal), and verbatims of all reported outcomes.

2.4 Study sampling

Before assessing full-text eligibility, a sampling strategy was used for COVID-19 studies, due to their very high numbers (n = 1804). Studies were excluded if abstract or country data were not available in the abstract (n = 577). Studies were subsequently included following these criteria: 1) all multi-country studies; 2) all intervention studies; 3) all studies if the number of studies per country was less than 10; 4) a random sample of 10 studies of non-interventional studies if the number of studies per country were more than 10. After the sampling described, 230 out of 737 studies from HICs and 197 out of 449 from LMICs were included. This approach allowed for limiting overrepresentation of respiratory disease outcomes or data from certain countries, as well as aided in optimizing the use of time and resources available to conduct the review. We did not envisage to exclude studies based on quality, therefore did not assess the risk of bias of studies or quality of the outcome reporting (Fig. 1).

Figure 1. Sampling strategy

2.5 Analysis

First, outcome verbatim homophones (different spelling of the same word) and synonyms pertaining to the same concept were categorized as one unique outcome (e.g., stillborn and fetal death were grouped under the outcome “stillbirth”). Then, unique outcomes were classified into domains and subdomains (Box 1), using a simplified domain classification based on the most recent recommendations of COMET 2018 [26]. The proportion of studies per type of study, country and region, infectious disease and mode of transmission were calculated, as well as frequency of maternal and neonatal outcomes.

The initial search yielded 9067 studies. After removing duplicates 8779 studies were screened by title and abstract, and 1976 studies were identified as relevant. Following the sampling process for COVID-19 studies described above, 1335 studies were further excluded. Subsequently, 641 studies underwent a comprehensive full-text selection, and finally, 440 studies were included. The study flow diagram is presented in Fig. 1. Supplement B details the list of included studies, and study characteristics.

Out of the included studies, 400 (90.9%) were epidemiological studies, 36 (8.2%) focused on post-authorization surveillance, and the remaining four studies (0.9%) described product developments. According to mode of transmission, respiratory diseases included a total of 351 studies (79.8%) on COVID-19, and 18 studies on influenza (4.1%). Among vector-borne diseases, zika was a subject of 55 studies (12.5%), chikungunya of six studies (1.4%), dengue of five studies (1.1%), and yellow fever of one (0.2%). Foodborne disease (cholera) was presented in two studies (0.5%), and one study each (0.2%) on hemorrhagic fever zoonosis, namely Ebola, Rift Valley fever. The total number of countries covered in our sampling was 107. In terms of regional distribution, 213 studies (38.2%) originated from the European region, 159 (28.6%) were from the Americas, 54 (9.7%) from the Eastern Mediterranean, 52 (9.3%) from the Western Pacific, 41 (7.4%) from the South-East Asia and 38 (6.8%) from the African region. Multi-country studies contributed to number of studies for each relevant region (Table 1).

Table 1

Characteristics of included studies
Characteristics	Number of studies (%)
Type of study
Epidemiological	400 (90.9%)
Product development	4 (0.9%)
Post-authorization surveillance	36 (8.2%)
Countries covered
Multi-country	42 (9.5%)
Single country	398 (90.5%)
Region*
Africa	38 (6.8%)
Americas	159 (28.6%)
Eastern Mediterranean	54 (9.7%)
Europe	213 (38.2%)
South-East Asia	41 (7.4%)
Western Pacific	52 (9.3%)
Infectious disease by mode of transmission
Airborne
Covid-19	351 (79.8%)
Influenza	18 (4.1%)
Vector-borne
Zika	55 (12.5%)
Chikungunya	6 (1.4%)
Dengue	5 (1.1%)
Yellow fever	1 (0.2%)
Hemorrhagic fevers zoonosis
Ebola hemorrhagic fever	1 (0.2%)
Rift valley fever	1 (0.2%)
Food/water-borne
Cholera	2 (0.5%)
*multi-country studies contributed to more than one region where applicable

We identified 917 distinct verbatims for maternal and pregnancy outcomes and further 657 neonatal outcomes, reaching respectively 1878 and 1026 verbatims, when accounting for repeated identical or similar verbatims. The complete list of verbatims ordered by unique outcome and frequency can be found in Supplement C. A total of 94 unique maternal and pregnancy outcomes and 47 unique neonatal outcomes were identified, after accounting for verbatims that covered similar concepts. Of those, 23 maternal and pregnancy outcomes (Table 2) and 12 neonatal outcomes were reported in at least 5.0% of all included studies (Table 3). The top ranking maternal and pregnancy outcomes were mode of delivery (247 studies; 56.1%), stillbirth (145; 33.0%), preterm birth/delivery (126; 28.6%), hypertensive disorders of pregnancy (117;26.6%), and maternal death (91 studies;20.7%).Top ranking neonatal outcomes were gestational age at birth (131 studies; 29.8%), congenital malformations of the nervous system (115; 26.1%), birth weight (103; 23.4%), admission to neonatal intensive care unit (NICU) related outbreak disease or other reason (102; 23.2%) and neonatal death (84; 19.1%). The complete lists of outcomes are presented in Supplement C.

Table 2

Most commonly reported maternal and pregnancy outcomes.
Maternal and pregnancy outcomes (n = 94)	Studies (n)	% (n/440)
Mode of delivery	247	56.1%
Stillbirth	145	33.0%
Preterm birth/delivery	126	28.6%
Hypertensive disorders of pregnancy	117	26.6%
Maternal death	91	20.7%
Spontaneous abortion	85	19.3%
Maternal admission to intensive care unit	77	17.5%
Depression	75	17.0%
Anxiety	61	13.9%
Gestational Diabetes Mellitus	50	11.4%
Maternal hospital admission/hospital stay	43	9.8%
Postpartum hemorrhage	43	9.8%
Maternal mechanical ventilation	41	9.3%
Premature rupture of membranes	40	9.1%
Maternal confirmed infection (related outbreak disease)	36	8.2%
Fetal growth restriction	33	7.5%
Stress	32	7.3%
Live birth	25	5.7%
Pneumonia	24	5.5%
Gestational age at delivery	23	5.2%
Maternal oxygen support	23	5.2%
Non-reassuring fetal status	22	5.0%
Preterm labor	22	5.0%

Note: The total number of outcomes identified was 94 in 440 studies. Most commonly reported outcomes were reported in at least 5.0% of all included studies. See complete lists of outcomes in Supplement C.

Table 3

Most commonly reported neonatal outcomes.
Neonatal outcomes reported (n = 47)	Studies (n)	% (n/440)
Gestational age at birth	131	29.8%
Congenital malformations of nervous system	115	26.1%
Birth weight	103	23.4%
Neonatal admission to intensive care unit (related outbreak disease or other reason)	102	23.2%
Neonatal death	84	19.1%
Size for gestational age	70	15.9%
Congenital malformations of eye, ear, face and neck	55	12.5%
Low or abnormal APGAR score	53	12.0%
Neonatal confirmed infection (related outbreak disease)	48	10.9%
APGAR score	44	10.0%
Any congenital malformation(s) or birth defects (non-specified)	32	7.3%
Respiratory failure	26	5.9%

Note: The total number of outcomes identified was 47 in 440 studies. Most commonly reported outcomes were reported in at least 5.0% of all included studies. See complete lists of outcomes in Supplement C.

Considering the reported outcomes by mode of transmission, the most frequently reported maternal and pregnancy outcome in studies of respiratory diseases (n = 369 studies) was mode of delivery (240; 65.0%), stillbirth (133; 36.3%) and preterm birth (120; 31.4%). In the group of neonatal outcomes, gestational age at birth (118; 32.5%), NICU admission (100; 27.1%), and birthweight (97; 24.7%) were the most frequently reported outcomes. Among vector-borne diseases, these were (n = 67 studies), spontaneous abortion (14; 20.9%), stillbirth (9; 13.4%), and mode of delivery (7; 10.4%). Of the neonatal outcomes, congenital malformations of the nervous system were reported 113 times, and included many different types of malformations, in a total of 67 studies (113/67). The two studies on virus zoonoses causing hemorrhagic fevers reported spontaneous abortion, with one reporting induced abortion, live birth, and stillbirth. Gestational age at birth was the sole neonatal outcome reported in these studies. In the two studies on foodborne or waterborne diseases, maternal outcomes of stillbirth and abortion, and neonatal outcomes of congenital malformations, gestational age at birth, and neonatal death were reported (Supplement D).

Looking at the outcome distribution per type of study, a total of 95 maternal and pregnancy outcomes, and 47 neonatal outcomes were reported in epidemiological studies. By comparison, 39 maternal and pregnancy outcomes and 19 neonatal outcomes were reported in post-authorization surveillance studies. The smallest number of outcomes was found in studies on product development − 19 and 6 respectively (Supplement E). The top 5 reported maternal outcomes (mode of delivery, stillbirth, preterm birth / delivery, hypertensive disorders of pregnancy, maternal death) were identified across all three types of studies. Only two outcomes reported across the different types of studies were reported in less than 5% of the included studies: antenatal bleeding of unspecified etiology and spontaneous preterm birth/ delivery. Only three neonatal outcomes were reported across all types of studies, two of them among the most reported ones: neonatal death, birth weight and arterial pH at birth (< 7.0-7.2).

The review identified 94 maternal and pregnancy outcomes, and 47 unique neonatal outcomes heterogeneously named and described in a large number of verbatims across 440 included studies. Mode of delivery, stillbirth, preterm birth, hypertensive disorders of pregnancy, and maternal death were among the most frequently reported maternal and pregnancy outcomes. These were gestational age at birth, congenital malformations of the nervous system, birth weight, neonatal admission to intensive care units, and neonatal death among neonatal outcomes .

The main strength of our study is the rigorous methods applied for conducting and reporting systematic reviews. Additionally, the external validity of our findings was expanded by the inclusion of alltypes of study designs, not only clinical trials, and use of no language restrictions. However, the review also has some limitations. The number of identified studies on effectiveness and efficacy was low, which hinders the understanding of the outcomes used in these studies, and the applicability of outcomes identified in this review to future interventional/product development studies. Furthermore, most of the studies addressed respiratory infections, mainly COVID-19 disease, which inevitably had an impact on frequency of reporting of identified outcomes, especially neonatal outcomes, which show some level of variation according to the mode of disease transmission. For COVID-19 studies, a sampling strategy was used to counteract the effect of their overrepresentation in the final list of outcomes. Although we did not formally check for saturation, a rapid exploration of COVID-19 studies not included in the review due to sampling strategy used, showed a high redundancy of outcomes. Admittedly, we could have missed some relevant studies published before 2015; but at the same time, we managed to cover several significant outbreaks that occurred in recent years, such as influenza. It should be noted that we identified a very high number of publications on COVID-19 disease which compensates for a relatively small number of included studies on other respiratory infectious disease outbreaks (e.g., Influenza 2009). There is also a possibility that we missed outcomes reported in smaller studies, that is those with less than 50 participants – and could potentially explain the very low number of studies that included covering hemorrhagic fever, zoonosis, or other recent outbreaks (e.g, Monkeypox). Finally, we failed to include studies reporting only on indirect effects of epidemics and pandemics (e.g., coverage or access to routine care such as number of prenatal visits), clinical presentation of disease – like fever, cough, headache – or risk factors. Other published COS, covering for example the COVID-19 disease and long-COVID condition, should be considered complementary to our efforts [27].

The top ranking maternal and pregnancy outcomes (mode of delivery, stillbirth, preterm birth/delivery, hypertensive disorders of pregnancy and maternal death), and neonatal outcomes (gestational age at birth, congenital malformations of nervous system, birthweight and neonatal admission to intensive care unit [related outbreak disease or other reason]) identified in this review includes outcomes commonly reported in maternal and perinatal health research, and does not reflect specific outcomes related to infectious diseases. This suggests that outcomes of interest may not depend on specific infectious diseases or mode of transmission. In fact, only a few top-rated outcomes identified in this review are disease specific or related to mode of transmission (maternal or neonatal confirmed infection and maternal pneumonia), and could indicate severity of infectious diseases (e.g., mortality, admission to ICU) or specific organ dysfunction (e.g., mechanical ventilation, need for oxygen support or respiratory failure). Although, relevance of certain outcomes may vary depending on the nature of the disease (e.g., zika infection and malformations). Surprisingly, mother-to-child transmission of infectious diseases was reported in relatively few (n = 13) studies included in the review. This could be related to challenges in defining vertical transmission early during the emergence of new infectious diseases [28].

Some of the unique pregnancy outcomes identified represent similar concepts and could be further combined. For example, spontaneous abortion/miscarriage, stillbirth, live birth, and neonatal death, represent a continuum of perinatal vital status [29]. However, depending on how studies are designed, it may not be possible to report outcomes across pregnancy trimester and after birth. This was evident during the COVID-19 pandemic where most studies covered late pregnancy and neonatal vital status, and few early pregnancy outcomes were covered [8, 30]. Other examples of overlap include low or abnormal APGAR score, reporting of actual APGAR score values, and birth asphyxia; or size for gestational age, which requires for its computation data on gestational age and birthweight. Other outcomes reported as maternal or neonatal outcomes represent similar outcomes, the only difference being whether these were reported in the obstetric or neonatal population in the studies included in this review. For example, preterm birth/delivery, gestational age at delivery or gestational age at birth all reflect gestational age at the end of a pregnancy and could be eventually considered as a unique outcome.

It is worth highlighting that among the most commonly reported outcomes were a few related to maternal mental health, such as depression, anxiety, and stress. All of these were reported in COVID-19 studies reflecting probably recent interest in maternal mental health and well-being, beyond survival and severe morbidity [31, 32]. For neonatal outcomes, a few outcomes related to newborn care (feeding and skin-to-skin) were reported in a small number of COVID-19 studies. The same applies for other outcomes of maternal cognitive or emotional functioning.

Several challenges remain unaddressed, such as the lack of comparability among studies and the difficulty in synthesizing data for meta-analyses. It is important to note that variations in reported outcomes in maternal and perinatal health are not exclusive to studies conducted in the context of epidemic threats; they have been observed across various maternal and perinatal conditions [33]. This is the case for outcomes such as stillbirths for which different gestational age and birthweight cut-off points are used, or variability in reporting vital status at birth, confounded by the need to appropriately assess gestational age at birth and birthweight. In consequence, misclassifications of perinatal status (stillbirths, live births and miscarriages) or prematurity may often occur [34]. Some other challenges relate to limited health workforce capabilities, availability of diagnostic technologies, and reporting systems, particularly in low-resource settings [35, 36].

The findings of this review underscore the critical necessity for standardized outcomes in maternal and neonatal research, especially during times of epidemics and pandemics. It will inform the development of a standardized core outcome set (COS) for maternal and neonatal outcomes, specifically tailored for research conducted amidst ongoing and emerging epidemic threats, that our group is currently conducting. We anticipate that this review and the subsequent development of a COS will not only contribute to the harmonization of maternal and perinatal health research during epidemics, but will also have broader implications for research in these areas beyond epidemic contexts.

LMICs

Low- and middle-income countries

PROSPERO

Prospective Register of Systematic Reviews

COMET

Core Outcome Measures in Effectiveness Trials

LILACS

Latin American and Caribbean Health Sciences Literature

SCI-EXPANDED

Science Citation Index Expanded

CINAHL

Cumulative Index to Nursing and Allied Health Literature

AMED

Allied and Complementary Medicine

ICTRP

International Clinical Trials Registry Platform

Florencia Salva

Vanesa Ortega

Carolina Nigri

MBa

Magdalena Babinska

NICU

neonatal intensive care unit

COS

Core Sutcome set

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

The datasets supporting the conclusions of this article is(are) included within the article and its additional files.

Competing interests

None.

Funding

This work was supported by the UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland, and the Bill and Melinda Gates Foundation (INV-041181 WHO).

Author´s contribution

Conceptualization: AM, MBerrueta, VP, AC, MBonet. Data curation, data analysis: MBerrueta, AM, MBabinska, AC. Formal analysis: AM, MBerrueta. Funding acquisition: MBonet. Data collection: MBabinska, FS, VO, CN. Supervision: AM, MBerrueta, VP, AC, MBonet. Writing-original draft: AM, MBerrueta, MBonet. Writing - review & editing: VP, MBabinska, CN, VO, FS, AC.

All authors provided comments and approved the final manuscript. The views of the funding bodies have not influenced the content of this manuscript. The named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO) or the other affiliated institutions.

Acknowledgements

We thank Dr. Karen Klein for her contributions in the presubmission inquires.

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The authors declare no competing interests.

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A systematic review of maternal and perinatal health outcomes in the context of epidemic threats: towards the development of a core outcome set.

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Abstract

Objective

Study design and Setting

Results

Conclusions

Figures

1. Introduction

2. Material and Methods

2.1 Inclusion and exclusion criteria

2.2 Search strategy

2.3 Selection of studies and data extraction

2.4 Study sampling

2.5 Analysis

3. Results

4. Discussion

5. Conclusions

List Of Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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