Association of armed conflict with extreme preterm birth and pre-eclampsia and eclampsia in Ukraine, 2022–24: a repeated cross-sectional national surveillance study

Abstract

Armed conflict can affect maternal and neonatal health through disruption of health services, population displacement, psychosocial stress, and deterioration of living conditions. However, population-based evidence obtained during large-scale modern warfare in countries with previously high-functioning maternal–newborn services remains sparse. We aimed to investigate whether rates of extreme preterm birth and pre-eclampsia or eclampsia among recorded facility-based deliveries in Ukraine changed during 2022–24 and whether these changes differed by regional conflict intensity. Methods We conducted a repeated cross-sectional national surveillance study of monthly aggregated facility-based deliveries recorded in Ukraine’s Ministry of Health forms N-21 (maternal outcomes) and N-21A (neonatal outcomes) from Feb 24, 2022, to Dec 31, 2024. Primary outcomes were extreme preterm birth (at 22–27 weeks’ gestation) and pre-eclampsia or eclampsia (defined using ICD-10 codes O14–O15). Secondary outcomes included early neonatal mortality (death at 0–6 days). We analysed temporal changes in outcomes using interrupted time-series models and examined regional contrasts in extreme preterm birth using difference-in-differences analyses comparing regions of high and low conflict exposure. Conflict intensity was defined using documented attacks on health facilities and front-line proximity. Poisson regression was used to estimate risk ratios (RRs), adjusted for maternal age, parity, facility type, urbanicity, and seasonality. Findings Recorded facility-based deliveries declined from 195243 in 2022 to 172230 in 2024. Rates of extreme preterm birth increased from 3·62 cases per 1000 deliveries in 2022 to 4·38 cases per 1000 deliveries in 2024 (adjusted RR 1·21 [95% CI 1·09–1·34]; p=0·0012). Pre-eclampsia or eclampsia increased from 66·7 cases per 1000 deliveries in 2022 to 88·5 cases per 1000 deliveries in 2024 (RR 1·33 [95% CI 1·28–1·38]; p=0·0014). Reported early neonatal mortality was lower in 2024 than in 2022 (1·71 deaths per 1000 deliveries in 2024 vs 2·1 deaths per 1000 deliveries in 2022; RR 0·81 [95% CI 0·70–0·94]). In regions with high exposure to conflict, 8·2 extreme preterm births per 1000 deliveries were recorded during 2022–24, compared with 3·1 extreme preterm births per 1000 deliveries in low-conflict regions (difference-in-differences estimate 2·1 [95% CI 1·4–2·8] per 1000 deliveries). Interpretation Among recorded facility-based deliveries in Ukraine from 2022 to 2024, increases in the rates of extreme preterm birth and pre-eclampsia or eclampsia were noted during the conflict period, with greater rates of extreme preterm birth in regions of high conflict exposure than in those with low conflict exposure. These findings might reflect a possible changing underlying population during wartime, because the number of recorded deliveries decreased from 2022 to 2024, and women who remained in Ukraine might have differed socioeconomically from those who left the country. The number and functionality of health facilities and reporting completeness also fell from 2022 to 2024, making selective under-ascertainment in conflict-affected areas likely, particularly in view of the decrease from 2022 to 2024 in recorded early neonatal mortality. Thus, these findings should be interpreted with caution as hypothesis-generating associations rather than direct estimates of population incidence.