The Insight into Obstetric Care near the Front Line in Kharkiv

Abstract. Objectives: The invasion of Russian troops into independent Ukraine has changed the humanitarian situation in the Kharkiv region. The paper is focused on the peculiarities and issues of the management of labor and delivery near the front line. Materials and methods: Totally 2030 patients were enrolled in the study. 1410 women who delivered in the second half of 2021 were enrolled in Group I. 620 women who delivered in the first half of 2022 were observed in Group II. Some patients from Group II were used for the investigation of the comparative situation during first months of 2022. 85 women who delivered in January were included in Subgroup IIA. 94 women who have completed their pregnancies and delivered in February were observed in Subgroup IIB. 67 case histories of deliveries which occurred during March were united in Subgroup IIC. Results: The level of anemia, uterine contractile activity in labor abnormalities, and episiotomies were surprisingly lower during wartime in March. The obtained results showed an almost similar level of obstetric complications, maternal comorbidities, and interventions during labor and delivery in all groups. The stressed environment was a possible reason for the elevation of cardiovascular disease and endocrine disorders. Conclusion: The study did not reveal any significant changes in the structure of maternal pathologies and obstetric complications during the first months of wartime near the front line. But later the levels of cardiovascular disease and endocrine disorders were found to be elevated.


Introduction
The invasion of Russian troops into independent Ukraine has changed the humanitarian situation in the Kharkiv region. Thus, all branches of the health care system have been modified in order to provide the population near the front line a qualified and highly-specialized medicine. The female reproductive system has been created by nature itself for a safe birth. The spontaneous onset of labor is a culmination of healthy pregnancy [1]. The mental stress and a continual threat of physical damage have a negative effect on maternal health [2][3][4].
Two options are known for the population of the regions located close to the area of the armed conflict. Some people ought to leave their homes becoming refugees. The problem of obstetric care in refugees is well known [5]. Several studies have shown an increased level of maternal and perinatal complications in such people [6]. But some pregnant women persist to stay in their native cities. They want to have a safe birth in their local maternal clinics under bombardment despite the continual sound of explosions [7,8]. Kharkiv municipal perinatal center is located in Saltivka near the border of the city. The staff of the maternal clinic had made significant efforts to follow all current findings and clinical protocols for obstetric care during the war [9][10][11]. The paper is focused on the peculiarities and issues of the management of labor and delivery near the front line.

Materials and Methods
A retrospective observational study was performed. The report of delivery unit activity and case histories of deliveries for the six months of the year 2022 and the previous six months of the year 2021 were analyzed. Totally 2030 patients were enrolled in the study. The inclusion criteria were pregnant women who delivered during this period. The exclusion criteria were all case of spontaneous or artificial pregnancy termination before 22 week of gestation. All patients who met the inclusion criteria gave informed consent to participate in the investigation. All ladies were divided into two groups. 1410 women who delivered in the second half of 2021 were enrolled in Group I. 620 women who delivered in the first half of 2022 were observed in Group II. Some patients from Group II were used for the investigation of the comparative situation during first months of 2022. 85 women who delivered in January were included in Subgroup IIA. 94 women who have completed their pregnancies and delivered in February were observed in Subgroup IIB. 67 case histories of deliveries which occurred during March were united in Subgroup IIC.
The study was done by examining the patient records of pregnant women in a hospital computer automation system. All available data including anamnesis, biometry, the variables of births, the level of maternal medical complications and obstetric interventions in labor and delivery were analyzed. We have followed the recommendations for the care of pregnant women in disaster setting [12]. The ACOG criteria for pre-eclampsia, anemia, gestational diabetes mellitus, and poor progress of labor were used [13][14][15][16][17][18].
Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS for Windows, Version 25.0, Chicago, IL, USA) program. The Chi-square test or Fischer's exact test (for 2x2 tables only) was used as a test of significance for qualitative data. A pvalue of less than 0.05 was accepted as statistically significant.

Results
The variables of age were not significantly different in Group I and Group II: 25.3±4.1 years and 25.0±4.6 years (p>0.05). The body mass index was 25.9±4.4 in Group I and 26.1±5.0 in Group II (p>0.05). The average age of the study population was not different in all subgroups: 24.6±4.1 years, 25.1±4.8 years, and 24.9±3.9 years, respectively, in Subgroup IIA, Subgroup IIB, and Subgroup IIC (p>0.05). The parity indices were in these subgroups, respectively: 1.5±0.4 and 1.6±0.5 (p>0.05). The variables of the body mass index were almost similar in Subgroup IIA, Subgroup IIB, and Subgroup IIC: 26.2±4.3, 25.9±3.2, and 26.4±5.6 (p>0.05). The indices of parity in the same subgroups were, respectively: 1.3±0.2, 1.4±0.3, and 1.3±0.3 (p>0.05). Thus, the homogeneity of the study population accordingly to their ages, anthropometric variables, and parity were detected.
The total quantity of deliveries was found to be decreased from the beginning of the war (Ta ble 1). The minimal number of births was registered in March. There were several multiple pregnan cies over three months' period. The level of normal deliveries was not different in all study groups. The level of presence of partners during labor was almost stable with an insignificant reduction in March. The only stillbirth occurred in February. The rate of Cesarean sections was similar in all groups. The number of breech births was not different amongst all study groups. Interestingly, 2 cases of breech delivery in February and 2 cases in March were found to be appropriate for vaginal birth. The incidence of preterm placental abruption was not significant (Table 2). Such cases were not registered in March. The maximal level of preeclampsia was found in February. The insignificant reduction of preeclampsia was registered in March. The manifestation of urinary tract infection was not different during peace and wartime. The findings of the insignificantly decreased incidence of anemia in Group II and Group III were not logical. The most disseminated medical problems dur ing pregnancy (cardiovascular disease and endocrine disorders) were found to have similar levels of manifestation in all study groups. The highest statistically significant rate of abnormal uterine contractile activity in labor was detected in February. A slight insignificant reduction of poor pro gress of labor was found in Group III. The only case of obstetrical hemorrhage occurred in January. The hysterectomy procedure was performed due to placental invasion in the area of the uterine scar. The statistically insignificant tendency to the reduction of episiotomies rate during wartime was detected. Two cases of the manual uterine revision due to retained placental tissue were registered in Group II and Group III. The soft vacuum for fetal extraction was used once in each study group.
The variable of birth did not change even during six months ( Table 3). The only significantly dif ferent index was partnership in labor. The number of birth was decreased. But the level of livebirth and Cesarean delivery was similar.   The variables of cardiovascular disease and endocrine disorders were higher in Group II ( Table  4). All other indices of gestational pathologies, complications in labor or postpartum, and obstetric interventions were not different. Therefore, the obstetric care in Kharkiv was stable.
The obtained results showed an almost similar level of obstetric complications, maternal comorbidities, and interventions during labor and delivery in all groups. Therefore, the obvious border between peace and wartime in their projection on maternal health and obstetric complication was not detected either within the first months or even later.

Discussion
The main issue in the conflict area is the feeling of being in an unsafe environment and unprotected [19]. Our pregnant women demonstrated courage and a brave spirit. They stayed home and deliv ered babies in their local perinatal center. They were aware of all risks of delivery under bombard ment. Kharkiv municipal perinatal center was damaged at the beginning of the war (Figure 1). De spite the danger, some pregnant ladies from Kharkiv took a chance and managed.
The psychological disorders during wartime could disturb female reproductive health or com plicate the current of gestation. The disorders of the female reproductive system are known both in civilian and military women [2025]. The increased level of mental disorders is involved in abnor mal fetal neurodevelopment [26]. The hypothesis of fetal programming was based on the negative impact of fetal growth restriction on its health in the future lifetime [27]. The increased incidence of gestational, obstetric, and perinatal complications is typical for the female population in the area of armed conflict and for refugees [2835]. But the variables of obstetric care during peace and wartime were almost similar in this study. The level of anemia, uterine contractile activity in labor abnormali ties, and episiotomies were surprisingly lower during wartime in March.
The level of partnership in labor was lower for the first half a year. The husbands left their families to defend Ukraine from the enemy. The stressed environment was a possible reason for the elevation of cardiovascular disease and endocrine disorders amongst pregnant ladies near front line [12].
Following the evidencebased clinical protocols was the main rule that contributed to beneficial maternal and perinatal outcomes. The use of modern perinatal technologies captured the significant professional level of the staff. The absence of obstetric aggression and the stable level of normal de livery were based on the current approaches to labor induction [36,37]. Active management was a measure for the prevention of prolonged stay in the clinic. It was not possible to collect patients in the department of fetomaternal medicine. The delayed stay in the clinic was associated with an in creased risk of damage. Thus, early discharge was a measure for the reduction of traumatic injuries.  Undoubtedly, modern obstetric care requires substantial support in medicines and medical de vices. Kharkiv municipal perinatal center received humanitarian aid from "Doctors without bor ders". This noble action contributed enormously to the support of safe birth in Saltivka near the frontline. Our clinic was provided with all necessary medications for urgent care in a disaster setting [12].
The findings of the study could be the repercussions of the strong traditions and reserves of the obstetric community in Kharkiv. Possibly, the changes in the humanitarian situation will contribute to the shift in maternal pathologies and obstetric complications ( Figure 2). Thus, further investiga tions are to be continued.
The paper highlighted the portrait of maternal diseases and obstetric pathology in the area of armed conflict.
The limitations of this study are a restricted period of observation and the different sizes of the study groups.

Conclusion
The study did not reveal any significant changes in the structure of maternal pathologies and ob stetric complications during the first months of wartime near the front line. But later the levels of cardiovascular disease and endocrine disorders were found to be elevated.

Conflicting interests
The author declares that he has no conflict of interest.

Funding
This work has not received any financial support.

Informed consent
Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.

Ethical approval
The ethics committee of Kharkiv Medical Academy of Postgraduate Education approved this study (REC number: 05.042022).