Childbirth and COVID-19
By Lily Li, Lily Owens, Isobel Beasley, Kathy Zhang and Isabelle Stevenson (members of the Melbourne University Health Initiative (MUHI) and mentored by the Global Health Alliance)
COVID-19 is the clinical syndrome caused when individuals become infected with SARS-CoV-2, and this pandemic has had a significant impact on all aspects of healthcare and society in general.(1) In particular, maternal health, pregnancy care and childbirth have been disrupted. This article explores the biopsychosocial impacts of COVID-19 on women, their children and their families. The authors explore the implications of COVID-19 on maternal and newborn health, the disruptions to care in both Australia and developing countries, and effects on domestic violence.
Medical Implications of COVID-19
Most literature suggests that pregnant women are not at increased risk of contracting severe forms of COVID-19 compared to the general public. However, pregnancy already affects the respiratory and cardiovascular systems, and COVID-19 further complicates this. The US Centres for Disease Control and Prevention found that among 91,412 women of reproductive age with coronavirus infections, the 8,207 who were pregnant were 6 times more likely to be hospitalised, 50% more likely to end up in intensive care units than their nonpregnant peers, and 70% more likely to need ventilators.(2)
Discomfort and fear of COVID-19 has also led to an increase in caesarean sections. A study conducted in Wuhan involving 118 pregnant women who were COVID-19 positive showed that among the 68 women who delivered during the study period, 93% underwent a caesarean section, due to both maternal complications and concerns about the effect of COVID-19 on pregnancy.(3) Of these, 21% deliveries were preterm.(3) In contrast, the ideal rate for caesarean sections is between 10% and 15% and it is known that unnecessary caesarean sections and premature deliveries have negative effects on maternal and newborn health.(3)
As a result, COVID-19 has significantly changed the way that healthcare services provide antenatal, childbirth and postnatal care for pregnant women and their families. These interruptions have been enacted so as to reduce the spread of COVID-19 to potentially vulnerable groups such as pregnant women, who have a history of susceptibility to respiratory viruses during pregnancy.(4) Antenatal care, traditionally run face-to-face, has been streamlined into predominantly telehealth appointments with face-to-face consultations at key moments across various health services. For example, the Mater Mothers Hospital in Brisbane runs telehealth appointments for all low risk pregnant women apart from three antenatal consultations, all of which coincide with vaccine delivery and ultrasonography.(5)
While these measures protect women medically from COVID-19 risk, they are not without social, emotional and spiritual cost for women and their families. These costs come primarily from the restriction on visitors within hospitals and at outpatient appointments, that leave pregnant women with limited access to their support people. For example, the Royal Women’s Hospital in Melbourne has mandated that one support person only may be present for labour and delivery with the same support person able to visit postnatal wards up to two hours a day. No children are able to visit within the hospital, and no support people are able to be present during in face antenatal and imaging consultations.(6) Additionally, the impact of COVID-19 has inhibited the capacity for face to face childbirth education classes and support spaces within the Royal Women’s Hospital such as the Women’s Welcome Centre.(7) While this helps to curb the spread of COVID-19 and medically protects pregnant women and their families, however in doing so, reduces the emotional and spiritual support that women receive during pregnancy and childbirth.
Despite all this, physical distancing measures have impacted the way women nurse their newborns very little. Most current literature suggests that the chance of vertical transmission of COVID-19 from mother to infant is very unlikely.(8) Peak bodies such as the Royal Australian and New Zealand College of Obstetricians and Gynecologists are still continuing to promote the importance of breastfeeding and skin-to-skin contact – though not without changes.(9) Parents are being encouraged to continue breastfeeding with particular attention to hand hygiene and wearing a mask, for example.(9,10) Even women with COVID-19 are being encouraged to continue breastfeeding, though there is some contention about the risks and benefits of direct breastfeeding versus expressed breast milk.(11)
Domestic Violence: A Pandemic within a Pandemic
A recent Lancet article cites experts at the UN Population Fund (UNPF) who have argued that gender-based violence has increased as a result of the COVID-19 crisis and is a “pandemic within a pandemic”.(12) Natalia Kanem, the executive director of the United Nations Partnership Framework, contends that the primary concern is that women are now restricted in their movements and are trapped in abusive relationships. Researchers from the University of Melbourne have suggested that job losses and financial stress, which have spiked during the pandemic, are likely to contribute to an increase in abuse and violence.(13) Due to lockdowns, social interactions are reduced and therefore, women have fewer opportunities to seek help.(14) Across China, Singapore, The United States, France, Argentina, and Cyprus domestic violence has reportedly increased from 10-33% during the pandemic.(15) Whilst the percentage increase differs across reports and countries, what is clear is that domestic violence has been exacerbated by COVID-19. But what does this mean for maternal health and childbirth?
Firstly, pregnant women have a higher risk of experiencing violence than non-pregnant women. (16) Pregnancy can be the period in which the first incidence of violence occurs or recurring violence is intensified. According to the Victorian Health Promotion Foundation, 39,100 and 414,600 Australian women have experienced violence while pregnant by a current or former live-in partner, respectively.(17) Shockingly, 61% and 47% of these women experienced the first episode of violence whilst pregnant. Hospital data shows that 11% of women hospitalised as a result intimate partner violence in Victoria were pregnant. A study from the US found that women had a three-fold higher risk of attempted or completed murder when pregnant.(18) Alarmingly, the risk was three-times greater again for black women, compared to white women. Together these data showed that pregnancy is a risk factor for family violence.
Secondly, violence during pregnancy increases health risks for mothers and babies. According to the Australian Government Department of Health’s Pregnancy Care Guidelines(18), women who experience violence whilst pregnant carry an increased risk of miscarriage, pre-term labour and birth, placental abruption, caesarean section, haemorrhage and infection. Additionally, the Australian Institute of Health and Welfare report (19) that women who are abused during their pregnancy are twice as likely to have babies with low birthweight, than women who were not abused. For newborns, this can lead to health complications later in life including diabetes and hypertension. In terms of maternal mental health, women who are victims of violence during pregnancy were more likely to report poor psychological health including depression and anxiety (19). This research highlights the need to focus on violence during the pandemic in order to safeguard the welfare of mothers and babies.
Global Perspectives: Impacts in Low- and Middle-Income Countries
Expectant mothers in low- and middle-income countries face unique challenges. Due to the devastation many diseases such as pneumonia, HIV and malaria continue to ravage on health systems and communities, fear surrounding COVID-19 is enormous.(20) Women are often turned away from medical facilities, if they aren’t turned off the idea of receiving care in already overstretched health systems. (20,21) Earlier this year in Papua New Guinea, a 19-year old heavily pregnant woman repeatedly tried to access medical help and was refused because the hospital had no way to confirm she wasn’t carrying the virus. (21) Likely suffering from pre-eclampsia, she later lost her child. (21)
Low- and middle- income countries also have less opportunity to reduce health services to reduce the spread of infection. High income countries such as Australia have reduced or delayed elective surgeries during the peak of infection. (22) Comparatively, most surgeries and health services in low- and middle- income countries are urgent emergency treatments. (22) For these countries, a decision must be taken between a lower infection rate by reducing essential health services and a higher infection rate under the status quo. (21,22) Even under the status quo, pregnant women struggle to access skilled medical staff and health education. In African nations, caesareans make up a significant proportion of all surgeries.(23) Delays or cancellations of these surgeries caused by coronavirus restrictions are likely to worsen already sobering maternal and neonatal mortality rates.
While the biological impacts of COVID-19 on pregnancy and childbirth are grave, so are the social implications. Disruptions to routine maternal healthcare amid the pandemic have physical and psychological consequences for both mother and baby. Many women are also faced with an escalation in domestic violence, especially while pregnant. The pandemic has also placed the health systems of low and middle income countries under further duress, further challenging pregnant women in these settings. The COVID-19 pandemic has affected modern life in many ways, and pregnancy, childbirth and maternal health are no exception to this.
The topic for this article was inspired by one of our recent meetings with our mentor, Misha Coleman, and her team. Misha used to be a midwife, and Shana, a member of her team, had just completed her training as a doula. We were also fortunate to have Associate Professor Alison Morgan present at our meeting, who shared her expertise in global maternal and child health.
Many of us shared the experiences of our own expectant family and friends, as well as what we had learned from our various educational backgrounds. We talked about the difficulties of giving birth or supporting someone during childbirth while adhering to physical distancing measures. We also discussed the importance of skilled birth attendants in developing nations, and Alison shared some of the challenges of starting, evaluating and maintaining these global health programs in the areas where they are needed.
Our group recognises that pregnancy and childbirth are not medical conditions, they are normal stages of life. Writing this article helped us explore the formal and scientific dimensions of the problem, but our mentoring session enabled us to delve into the social and global health-related aspects. Especially in the age of COVID-19, when so much of “normal” life has been disrupted.
- Australian Government Department of Health. What you need to know about coronavirus (COVID-19) [Internet]. Canberra (ACT): Australian Government Department of Health; 2020 [updated 2020; cited 2020 Aug 9]. Available from: https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/what-you-need-to-know-about-coronavirus-covid-19
- Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Zambrano LD, Nahabedian J, Anderson K, Gilboa SM. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–June 7, 2020. Morbidity and Mortality Weekly Report. 2020 Jun 26;69(25):769.
- Chen L, Li Q, Zheng D, Jiang H, Wei Y, Zou L, Feng L, Xiong G, Sun G, Wang H, Zhao Y. Clinical characteristics of pregnant women with Covid-19 in Wuhan, China. New England Journal of Medicine. 2020 Apr 17.
- Maternity and neonatal care during COVID-19 [internet]. Melbourne: Department of Health and Human Services Victoria; 2020 Jul 16. Available from: https://www.dhhs.vic.gov.au/covid-19-guideline-maternity-and-neonatal-care
- Lewin, E. Maternity care during COVID19 [internet]. Melbourne: Royal Australian College of General Practitioners; 2002 Apr 8. Available from: https://www1.racgp.org.au/newsgp/clinical/maternity-care-during-covid-19
- New visitors policy [internet]. Melbourne; The Royal Women’s Hospital. Available from: https://www.thewomens.org.au/patients-visitors/covid-19-advice-and-updates/new-visitor-guidelines/
- The Women’s Welcome Centre [internet]. Melbourne; The Royal Women’s Hospital. Available from: https://www.thewomens.org.au/patients-visitors/your-visit/womens-welcome-centre/
- Yan J, Guo J, Fan C, Juan J, Yu X, Li J, Feng L, Li C, Chen H, Qiao Y, Lei D. Coronavirus disease 2019 (COVID-19) in pregnant women: A report based on 116 cases. American journal of obstetrics and gynecology. 2020 Apr 23.
- The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Info for Pregnant Women [Internet]. RANZCOG. [cited 2020 Aug 9]. Available from: https://ranzcog.edu.au/statements-guidelines/covid-19-statement/information-for-pregnant-women
- The Royal Women’s Hospital. Advice for breastfeeding women [Internet]. The Royal Women’s Hospital. [cited 2020 Aug 9]. Available from: https://www.thewomens.org.au/patients-visitors/covid-19-advice-and-updates/advice-for-breastfeeding-women
- Stanojević M. Are Covid-19-positive mothers dangerous for their term and well newborn babies? Is there an answer? Journal of Perinatal Medicine. 2020 Jun 25;48(5):441–5.
- Cousins S. COVID-19 has “devastating” effect on women and girls. The Lancet. 2020 Aug 1;396(10247):301-2. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31679-2/fulltext?fbclid=IwAR1MR74zLgNZgg5c7qrKgAz1LgOBmB9eJegZNYqMSvt8423eTLKg43rl03o
- Hegarty K, Tarzia, L. Domestic Violence, Isolation and Covid-19 [Internet]. Melbourne (VIC): Pursuit; 2020 [updated 2020; cited 2020 Aug 8]. Available from: https://pursuit.unimelb.edu.au/articles/domestic-violence-isolation-and-covid-19
- Gausman J, Langer A. Sex and gender disparities in the COVID-19 pandemic. Journal of Women’s Health. 2020 Apr 1;29(4):465-6. Available from: https://www.liebertpub.com/doi/pdfplus/10.1089/jwh.2020.8472
- Boserup B, McKenney M, Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic. The American Journal of Emergency Medicine. 2020 Apr 28. Available from: https://www.ajemjournal.com/article/S0735-6757(20)30307-7/fulltext
- Victorian Health Promotion Foundation. Violence against Women in Australia: An Overview of Research and Approaches to Primary Prevention. VicHealth; 2017. Available from: http://www.hwpcp.org.au/wp-content/uploads/2017/07/Violence-Against-Women-Research-Overview.pdf
- McFarlane J, Campbell JC, Sharps P, Watson K. Abuse during pregnancy and femicide: urgent implications for women’s health. Obstetrics & Gynecology. 2002 Jul 1;100(1):27-36. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0029784402020549
- Australian Government Department of Health. Pregnancy Care Guidelines: 29 Family violence [Internet]. Canberra (ACT): Australian Government Department of Health; 2020 [updated 2018; cited 2020 Aug 9]. Available from: https://www.health.gov.au/resources/pregnancy-care-guidelines/part-e-social-and-emotional-screening/family-violence
- Australian Institute of Health and Welfare 2019. Family, domestic and sexual violence in Australia: continuing the national story 2019. Canberra: AIHW. Available from: https://www.aihw.gov.au/reports/domestic-violence/family-domestic-sexual-violence-australia-2019/contents/table-of-contents
- Shuchman M. Low- and middle-income countries face up to COVID-19: As cases of COVID-19 are being declared the Global South, low- and middle-income countries brace themselves for the pandemic. Nature Medicine [Internet]. 2020 May 21 [cited 2020 Aug 9]. Available from: https://www.nature.com/articles/d41591-020-00020-2
- Whiting N. Coronavirus fears leave pregnant PNG women at risk despite nation’s low infection rate. ABC News [Internet]. 2020 Jun 25 [cited 2020 Aug 9]. Available from: https://www.abc.net.au/news/2020-06-25/pregnant-png-women-not-getting-care-due-to-coronavirus-fears/12380436
- Bong CL, Brasher C, Chikumba E, McDougall R, Mellin-Olsen J, Enright A. The COVID-19 Pandemic: Effects on Low-and Middle-Income Countries. Anesthesia and analgesia. 2020 Apr 20.
- Kushner AL, Groen RS, Kingham TP. Percentage of cesarean sections among total surgical procedures in sub-Saharan Africa: possible indicator of the overall adequacy of surgical care. World journal of surgery. 2010 Sep 1;34(9):2007-8