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      Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries

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      1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 1 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 4 , 39 , 40 , 41 , 42 , 2 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 1 , 56 , 57 , 58 , 59 , 60 , 19 , 61 , 62 , 63 , 64 , 65 , 50 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 1 , 73 , 74 , 75 , 39 , 76 , 50 , 77 , 78 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 50 , 89 , 90 , 91 , 19 , 19 , 27 , 28 , 29 , 92 , 93 , 94 , 95 , 96 , 97 , 87 , 5 , 98 , 99 , 100 , 101 , 83 , 102 , 103 , 104 , 105 , 106 , 107 , 65 , 102 , 108 , 66 , 67 , 68 , 1 , 109 , 110 , 111 , 112 , 113 , 1 , 2 , 5 , 6 , , 1 , , 2 , 114 ,
      Nature Human Behaviour
      Nature Publishing Group UK
      Outcomes research, Epidemiology

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          Abstract

          Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from −90% to +30%, were reported in many countries following early COVID-19 pandemic response measures (‘lockdowns’). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95–0.98, P value <0.0001), second (0.96, 0.92–0.99, 0.03) and third (0.97, 0.94–1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96–1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88–1.14, 0.98), third (0.99, 0.88–1.12, 0.89) and fourth (1.01, 0.87–1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02–1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03–1.15, 0.002), third (1.10, 1.03–1.17, 0.003) and fourth (1.12, 1.05–1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways.

          Abstract

          An analysis of 52 million births in 26 countries shows small reductions in preterm birth during the first to third months of lockdown. Further research is needed to examine causal pathways.

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          Most cited references62

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              Is Open Access

              Interrupted time series regression for the evaluation of public health interventions: a tutorial

              Abstract Interrupted time series (ITS) analysis is a valuable study design for evaluating the effectiveness of population-level health interventions that have been implemented at a clearly defined point in time. It is increasingly being used to evaluate the effectiveness of interventions ranging from clinical therapy to national public health legislation. Whereas the design shares many properties of regression-based approaches in other epidemiological studies, there are a range of unique features of time series data that require additional methodological considerations. In this tutorial we use a worked example to demonstrate a robust approach to ITS analysis using segmented regression. We begin by describing the design and considering when ITS is an appropriate design choice. We then discuss the essential, yet often omitted, step of proposing the impact model a priori. Subsequently, we demonstrate the approach to statistical analysis including the main segmented regression model. Finally we describe the main methodological issues associated with ITS analysis: over-dispersion of time series data, autocorrelation, adjusting for seasonal trends and controlling for time-varying confounders, and we also outline some of the more complex design adaptations that can be used to strengthen the basic ITS design.
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                Author and article information

                Contributors
                david.burgner@mcri.edu.au
                sarah.stock@ed.ac.uk
                meghan.azad@umanitoba.ca
                Journal
                Nat Hum Behav
                Nat Hum Behav
                Nature Human Behaviour
                Nature Publishing Group UK (London )
                2397-3374
                27 February 2023
                27 February 2023
                2023
                : 7
                : 4
                : 529-544
                Affiliations
                [1 ]GRID grid.4305.2, ISNI 0000 0004 1936 7988, Usher Institute, , University of Edinburgh, ; Edinburgh, UK
                [2 ]GRID grid.21613.37, ISNI 0000 0004 1936 9609, Children’s Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, , University of Manitoba, ; Winnipeg, Manitoba Canada
                [3 ]GRID grid.1005.4, ISNI 0000 0004 4902 0432, School of Population Health, Faculty of Medicine & Health, , University of New South Wales Sydney, ; Sydney, New South Wales Australia
                [4 ]GRID grid.14013.37, ISNI 0000 0004 0640 0021, Centre of Public Health Sciences, Faculty of Medicine, , University of Iceland, ; Reykjavik, Iceland
                [5 ]GRID grid.416107.5, ISNI 0000 0004 0614 0346, Murdoch Children’s Research Institute, Royal Children’s Hospital, ; Parkville, Victoria Australia
                [6 ]GRID grid.1008.9, ISNI 0000 0001 2179 088X, Department of Paediatrics, , University of Melbourne, ; Parkville, Victoria Australia
                [7 ]GRID grid.5645.2, ISNI 000000040459992X, Division of Neonatology, Department of Paediatrics; Department of Obstetrics and Gynaecology; Department of Public Health; Erasmus MC - Sophia Children’s Hospital, , University Medical Centre Rotterdam, ; Rotterdam, the Netherlands
                [8 ]GRID grid.413081.f, ISNI 0000 0001 2322 8567, Public Health Research Group, Department of Biomedical Sciences, , University of Cape Coast, ; Cape Coast, Ghana
                [9 ]GRID grid.419481.1, ISNI 0000 0001 1515 9979, Novartis, ; Basel, Switzerland
                [10 ]GRID grid.412989.f, ISNI 0000 0000 8510 4538, Department of Pediatrics, , University of Jos/Jos University Teaching Hospital, ; Jos, Nigeria
                [11 ]GRID grid.168010.e, ISNI 0000000419368956, Department of Anesthesiology, Pain, and Perioperative Medicine, , Stanford University School of Medicine, ; Stanford, CA USA
                [12 ]GRID grid.412962.a, ISNI 0000 0004 1764 9404, Institute of Health Research and Development, , University of Uyo Teaching Hospital, ; Uyo, Nigeria
                [13 ]GRID grid.412960.8, ISNI 0000 0000 9156 2260, College of Health Sciences, , University of Uyo, ; Uyo, Nigeria
                [14 ]GRID grid.22072.35, ISNI 0000 0004 1936 7697, Department of Pediatrics, , University of Calgary, ; Calgary, Alberta Canada
                [15 ]GRID grid.9582.6, ISNI 0000 0004 1794 5983, Department of Pediatrics, , College of Medicine, University of Ibadan and University College Hospital, ; Ibadan, Nigeria
                [16 ]Canadian Premature Babies Foundation, Toronto, Ontario Canada
                [17 ]GRID grid.411036.1, ISNI 0000 0001 1498 685X, Department of Pediatrics, Division of Neonatology, Child Growth and Development Research Center, , Isfahan University of Medical Sciences, ; Isfahan, Iran
                [18 ]Aridhia Informatics, Glasgow, UK
                [19 ]Obstetrics and Gynaecology Ward, District Public Hospital in Poznań, Poznań, Poland
                [20 ]GRID grid.14848.31, ISNI 0000 0001 2292 3357, Faculty of Pharmacy, , University of Montreal, ; Montreal, Quebec Canada
                [21 ]GRID grid.411418.9, ISNI 0000 0001 2173 6322, CHU Ste-Justine, ; Montreal, Quebec Canada
                [22 ]GRID grid.7849.2, ISNI 0000 0001 2150 7757, Faculty of Medicine, , Université Claude Bernard Lyon 1, ; Lyon, France
                [23 ]GRID grid.7147.5, ISNI 0000 0001 0633 6224, Center of Excellence in Women Child Health, , The Aga Khan University, ; Karachi, Pakistan
                [24 ]GRID grid.42327.30, ISNI 0000 0004 0473 9646, Centre for Global Child Health, Hospital for Sick Children, ; Toronto, Ontario Canada
                [25 ]GRID grid.17063.33, ISNI 0000 0001 2157 2938, Dalla Lana School of Public Health, , University of Toronto, ; Toronto, Ontario Canada
                [26 ]Department of Obstetrics & Gynaecology and Child Health, University of The West MonaIndies, Mona, Jamaica
                [27 ]GRID grid.5645.2, ISNI 000000040459992X, The Generation R Study Group, Erasmus MC, , University Medical Center Rotterdam, ; Rotterdam, The Netherlands
                [28 ]GRID grid.5645.2, ISNI 000000040459992X, The Department of Paediatrics, Erasmus MC, , University Medical Center Rotterdam, ; Rotterdam, The Netherlands
                [29 ]GRID grid.11100.31, ISNI 0000 0001 0673 9488, Centro de Investigación en Salud Materna e Infantil and Centro de Investigación para el Desarrollo Integral y Sostenible, , Universidad Peruana Cayetano Heredia, ; Lima, Peru
                [30 ]GRID grid.55602.34, ISNI 0000 0004 1936 8200, School of Nursing, , Dalhousie University and IWK Health, ; Halifax, Nova Scotia Canada
                [31 ]GRID grid.267852.c, ISNI 0000 0004 0637 2083, Center for Biomedicine and Community Health, International School, , Vietnam National University, ; Hanoi, Vietnam
                [32 ]GRID grid.34428.39, ISNI 0000 0004 1936 893X, Department of Health Sciences, , Carleton University, ; Ottawa, Ontario Canada
                [33 ]GRID grid.420036.3, ISNI 0000 0004 0626 3792, AZ St-Jan Bruges-Ostend AV Hospital, ; Bruges, Belgium
                [34 ]GRID grid.512263.1, Department of Public Health, School of Medicine, Advanced Center for Chronic Diseases Diagonal (ACCDIS), ; Santiago, Chile
                [35 ]Irish Neonatal Health Alliance, Wicklow, Ireland
                [36 ]GRID grid.48769.34, ISNI 0000 0004 0461 6320, Department of Neonatology, , Cliniques Universitaires Saint-Luc, IREC, UCLouvain, ; Brussels, Belgium
                [37 ]CEpiP (Centre d’Epidémiologie Périnatale), Brussels, Belgium
                [38 ]GRID grid.414821.a, Department of Paediatrics, Federal Medical Centre, ; Abeokuta, Nigeria
                [39 ]GRID grid.1032.0, ISNI 0000 0004 0375 4078, Curtin School of Population Health, , Curtin University, ; Perth, Western Australia Australia
                [40 ]GRID grid.418193.6, ISNI 0000 0001 1541 4204, Department of Health Registry Research and Development, Norwegian Institute of Public Health, ; Oslo, Norway
                [41 ]GRID grid.419218.7, ISNI 0000 0004 1773 5302, National Institute of Perinatology, ; Mexico City, Mexico
                [42 ]GRID grid.418712.9, ISNI 0000 0004 1760 7415, Institute for Maternal and Child Health, IRCCS Burlo Garofolo Children’s Hospital, ; Trieste, Italy
                [43 ]GRID grid.17063.33, ISNI 0000 0001 2157 2938, Department of Statistical Sciences and School of the Environment, , University of Toronto, ; Toronto, Ontario Canada
                [44 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, Population Health Sciences, Bristol Medical School, , University of Bristol, ; Bristol, UK
                [45 ]GRID grid.10604.33, ISNI 0000 0001 2019 0495, Obstetrics and Gynecology, Medicine, , University of Nairobi, ; Nairobi, Kenya
                [46 ]GRID grid.1003.2, ISNI 0000 0000 9320 7537, School of Biomedical Sciences, , The University of Queensland, ; St. Lucia, Queensland Australia
                [47 ]GRID grid.14758.3f, ISNI 0000 0001 1013 0499, Department of Knowledge Brokers, , THL Finnish Institute for Health and Welfare, ; Helsinki, Finland
                [48 ]Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
                [49 ]GRID grid.4714.6, ISNI 0000 0004 1937 0626, Department of Molecular Medicine and Surgery, Karolinska Institutet, ; Stockholm, Sweden
                [50 ]GRID grid.418193.6, ISNI 0000 0001 1541 4204, Centre for Fertility and Health, Norwegian Institute of Public Health, ; Oslo, Norway
                [51 ]GRID grid.415814.d, ISNI 0000 0004 0612 272X, Neonatology, Neonatal Health Office, Ministry of Health and Medical Education, ; Tehran, Iran
                [52 ]GRID grid.417720.7, ISNI 0000 0004 0384 7389, Cytel, ; Waltham, MA USA
                [53 ]GRID grid.264200.2, ISNI 0000 0000 8546 682X, St. George’s University, Makerere University - Johns Hopkins University Research Collaboration, ; London, UK
                [54 ]GRID grid.1008.9, ISNI 0000 0001 2179 088X, Department of Obstetrics and Gynaecology, , University of Melbourne, ; Melbourne, Victoria Australia
                [55 ]GRID grid.11100.31, ISNI 0000 0001 0673 9488, Centro de Investigación en Salud Materna e Infantil, Centro de Investigación para el Desarrollo Integral y Sostenible and School of Medicine, , Universidad Peruana Cayetano Heredia, ; Lima, Peru
                [56 ]GRID grid.414142.6, ISNI 0000 0004 0600 7174, Nutrition and Clinical Services Division, ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh), ; Dhaka, Bangladesh
                [57 ]GRID grid.8993.b, ISNI 0000 0004 1936 9457, Uppsala University, ; Uppsala, Sweden
                [58 ]GRID grid.454382.c, ISNI 0000 0004 7871 7212, Oxford Vaccine Group, Department of Paediatrics, , University of Oxford and the NIHR Oxford Biomedical Research Centre, ; Oxford, UK
                [59 ]GRID grid.411036.1, ISNI 0000 0001 1498 685X, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, , Isfahan University of Medical Sciences, ; Isfahan, Iran
                [60 ]GRID grid.411746.1, ISNI 0000 0004 4911 7066, Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, , Iran University of Medical Sciences, ; Tehran, Iran
                [61 ]GRID grid.4464.2, ISNI 0000 0001 2161 2573, International Centre for Neonatal and Paediatric Infection, St. George’s, , University of London, ; London, UK
                [62 ]GRID grid.415861.f, ISNI 0000 0004 1790 6116, Medical Research Council/Uganda Virus Research Institute and London School of Medical Hygiene & Tropical Medicine Uganda Research Unit, ; Entebbe, Uganda
                [63 ]GRID grid.7821.c, ISNI 0000 0004 1770 272X, Universidad de Cantabria, ; Santander, Spain
                [64 ]GRID grid.466571.7, ISNI 0000 0004 1756 6246, CIBERESP (Consortium for Biomedical Research in Epidemiology & Public Health, en Epidemiología y Salud Pública), ; Madrid, Spain
                [65 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, Institute of Women and Children’s Health, School of Life Course and Population Sciences, King’s College London, ; London, UK
                [66 ]GRID grid.83440.3b, ISNI 0000000121901201, Research Department of Practice and Policy, , University College London School of Pharmacy, ; London, UK
                [67 ]GRID grid.194645.b, ISNI 0000000121742757, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, , The University of Hong Kong, ; Hong Kong, Hong Kong
                [68 ]Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong, Hong Kong
                [69 ]GRID grid.411943.a, ISNI 0000 0000 9146 7108, Department of Child Health and Paediatrics, School of Medicine, , Jomo Kenyatta University of Agriculture and Technology, ; Nairobi, Kenya
                [70 ]GRID grid.168010.e, ISNI 0000000419368956, Division of Pediatric Hospital Medicine, Department of Pediatrics, , Stanford University School of Medicine, ; Stanford, CA USA
                [71 ]GRID grid.507332.0, ISNI 0000 0004 9548 940X, Health Data Research UK, ; London, UK
                [72 ]GRID grid.25152.31, ISNI 0000 0001 2154 235X, Community Health and Epidemiology, College of Medicine, , University of Saskatchewan, ; Saskatoon, Saskatchewan Canada
                [73 ]Melletted a helyem Egyesület, Right(s) Beside You Association, Budapest, Hungary
                [74 ]GRID grid.461255.1, ISNI 0000 0004 1780 2544, Department of Paediatrics, St. Francis Nsambya Hospital, ; Kampala, Uganda
                [75 ]GRID grid.1013.3, ISNI 0000 0004 1936 834X, Child Population and Translational Health Research, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, , University of Sydney, ; Sydney, New South Wales Australia
                [76 ]Education, Culture, and Health Opportunities (ECHO) Research Group International, Aflao, Ghana
                [77 ]GRID grid.8991.9, ISNI 0000 0004 0425 469X, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, ; London, UK
                [78 ]GRID grid.9582.6, ISNI 0000 0004 1794 5983, Department of Obstetrics and Gynaecology, College of Medicine, , University of Ibadan and University College Hospital, ; Ibadan, Nigeria
                [79 ]Lagos Island Maternity Hospital, Lagos, Nigeria
                [80 ]Department of Paediatrics and Child Health, Mother and Child Hospital, Akure, Nigeria
                [81 ]Department of Paediatrics, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
                [82 ]GRID grid.4827.9, ISNI 0000 0001 0658 8800, Swansea University, ; Swansea, UK
                [83 ]GRID grid.4714.6, ISNI 0000 0004 1937 0626, Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, ; Stockholm, Sweden
                [84 ]Department of Obstetrics and Gynecology, Visby County Hospital, Visby, Sweden
                [85 ]GRID grid.421981.7, Makerere University - Johns Hopkins University Research Collaboration, ; Kampala, Uganda
                [86 ]Paediatrics Department, Ikorodu General Hospital, Ikorodu, Nigeria
                [87 ]GRID grid.1002.3, ISNI 0000 0004 1936 7857, Department of Obstetrics and Gynaecology, , Monash University, ; Clayton, Victoria Australia
                [88 ]GRID grid.7048.b, ISNI 0000 0001 1956 2722, Department of Obstetrics and Gynecology, , Aarhus University and Aarhus University Hospital, ; Aarhus, Denmark
                [89 ]GRID grid.1032.0, ISNI 0000 0004 0375 4078, Curtin School of Population Health and enAble Institute, , Curtin University, ; Perth, Western Australia Australia
                [90 ]GRID grid.411964.f, ISNI 0000 0001 2224 0804, School of Nutrition, , Catholic University del Maule, ; Region del Maule, Chile
                [91 ]GRID grid.488552.6, Division of Neonatology, Department of Paediatrics, , University Maternity Hospital Limerick and University of Limerick School of Medicine, ; Limerick, Ireland
                [92 ]GRID grid.267103.1, ISNI 0000 0004 0461 8879, School of Nursing and Health Professions, , University of San Francisco, ; San Francisco, CA USA
                [93 ]GRID grid.7836.a, ISNI 0000 0004 1937 1151, Paediatric Department, School of Adolescent and Child Health, , University of Cape Town, ; Cape Town, South Africa
                [94 ]GRID grid.467135.2, ISNI 0000 0004 0635 5945, Mowbray Maternity Hospital, Western Cape Department of Health, ; Cape Town, South Africa
                [95 ]GRID grid.438284.1, ISNI 0000 0001 0789 6274, Federal Statistical Office (FSO), ; Neuchâtel, Switzerland
                [96 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Epidemiology, , University of Washington, ; Seattle, WA USA
                [97 ]GRID grid.4437.4, ISNI 0000 0001 0505 4321, Evidence and Intelligence for Action in Health Department, Pan-American Health Organization - World Health Organization, ; Washington, DC USA
                [98 ]GRID grid.411656.1, ISNI 0000 0004 0479 0855, Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, , Inselspital, Bern University Hospital, University of Bern, ; Bern, Switzerland
                [99 ]GRID grid.5734.5, ISNI 0000 0001 0726 5157, Department of Biomedical Research, , University of Bern, ; Bern, Switzerland
                [100 ]GRID grid.1013.3, ISNI 0000 0004 1936 834X, The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, , The University of Sydney, ; Sydney, New South Wales Australia
                [101 ]GRID grid.417446.4, ISNI 0000 0004 0618 8147, Foundation for Health Care Quality, ; Seattle, WA USA
                [102 ]GRID grid.189504.1, ISNI 0000 0004 1936 7558, Department of Environmental Health, , Boston University School of Public Health, ; Boston, MA USA
                [103 ]GRID grid.14013.37, ISNI 0000 0004 0640 0021, Faculty of Nursing, Department of Midwifery, , University of Iceland, ; Reykjavík, Iceland
                [104 ]GRID grid.11804.3c, ISNI 0000 0001 0942 9821, Division of Neonatology, 1st Department of Pediatrics, , Semmelweis University, ; Budapest, Hungary
                [105 ]GRID grid.470490.e, Centre of Excellence in Women and Child Health, , Aga Khan University, ; Nairobi, Kenya
                [106 ]GRID grid.7836.a, ISNI 0000 0004 1937 1151, Department of Paediatrics, , University of Cape Town, ; Cape Town, South Africa
                [107 ]GRID grid.21613.37, ISNI 0000 0004 1936 9609, Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, , University of Manitoba, ; Winnipeg, Manitoba Canada
                [108 ]GRID grid.1008.9, ISNI 0000 0001 2179 088X, The Royal Women’s Hospital, , University of Melbourne, ; Melbourne, Victoria Australia
                [109 ]GRID grid.508718.3, Public Health Scotland, ; Edinburgh, UK
                [110 ]GRID grid.22254.33, ISNI 0000 0001 2205 0971, II Department of Neonatology, , Poznań University of Medical Sciences, ; Poznań, Poland
                [111 ]Public Health Unit, Father Thomas Alan Rooney Memorial Hospital, Asankrangwa, Western Region, Ghana
                [112 ]GRID grid.412989.f, ISNI 0000 0000 8510 4538, Department of Paediatrics, , University of Jos, ; Jos, Nigeria
                [113 ]GRID grid.22254.33, ISNI 0000 0001 2205 0971, Department of Medical Simulation, Chair of Medical Education, , Poznań University of Medical Sciences, ; Poznań, Poland
                [114 ]GRID grid.21613.37, ISNI 0000 0004 1936 9609, Departments of Pediatrics and Child Health, Community Health Sciences, and Immunology, , University of Manitoba, Winnipeg, Manitoba, Canada, ; Winnipeg, Manitoba Canada
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                http://orcid.org/0000-0003-1772-1798
                http://orcid.org/0000-0003-4343-774X
                http://orcid.org/0000-0002-7370-5525
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                http://orcid.org/0000-0002-0213-6935
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                http://orcid.org/0000-0002-4697-4316
                http://orcid.org/0000-0002-5489-8333
                http://orcid.org/0000-0002-5822-7043
                http://orcid.org/0000-0001-5122-6577
                http://orcid.org/0000-0002-7243-7741
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                Article
                1522
                10.1038/s41562-023-01522-y
                10129868
                36849590
                2edafcf4-3bee-4e92-a482-53067bb46bbd
                © The Author(s) 2023

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 29 April 2022
                : 6 January 2023
                Funding
                Funded by: This work was supported by the International COVID-19 Data Alliance (ICODA), an initiative funded by the Bill and Melinda Gates Foundation and Minderoo as part of the COVID-19 Therapeutics Accelerator and convened by Health Data Research (HDR) UK, in addition to support from the HDR UK BREATHE Hub. Sources of support for individual datasets and co-authors are listed in Appendix 14. Several ICODA partners contributed to the study, including: Cytel (statistical support), the Odd Group (data visualization), and Aridhia Informatics (development of federated analysis using a standardized protocol ([Common API] https://github.com/federated-data-sharing/) to be used in future work).
                Funded by: See above for Corresponding Author Dr. Meghan Azad.
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                © Springer Nature Limited 2023

                outcomes research,epidemiology
                outcomes research, epidemiology

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