September 09, 2020

COVID-19 impacts all maternity care

 The Campion Fund is dedicated to the promotion of fundamental reproductive science and the education of the public about all aspects of this field. I doing so we hope to promote an understanding of why and how providers should give up to date, evidence- based care. We are dedicated to demonstrating the science behind care. This is the reason we are writing this blog. As I write this it is reported that world-wide about 8% of pregnant women and postpartum women with COVID-19 have serious disease and approximately 1% are critically ill. The US CDC reports that as of September 3, 2020  there had been 20,216 pregnant women with COVID-19 and 44 deaths reported to them. 4796 pregnant women were hospitalized. The CDC indicates that the most infections are among Latino, Hispanic mothers but both Black women and white women contribute to these numbers as well. Fewer Asian women have been reported to have COVID-19 during pregnancy. These numbers, however, are incomplete as many of the COVID-19 case reports sent to the CDC do not give pregnancy status. The true impact of the SARS-CoV2 on childbearing will not be understood for some time because of this incomplete data collection and also because the pandemic is not yet over. The prevalence of COVID-19  among childbearing women as reported currently differs by geographical location. There was a 3.9% prevalence among 782 pregnant women in three Yale-New Haven Hospitals in Connecticut reported earlier this spring, while in there was a 13.5% prevalence of coronavirus infection among women giving birth in New Work City.  Currently, NIH is collecting data on COVID -19 and pregnancy outcomes and professional groups and university departments, especially UCSF are gathering information on the subject through their registries and will over time provide more information for evaluation of the impact of the pandemic on childbirth.

However, a very serious impact of COVID-19 on childbearing in our country is rapidly becoming apparent. This jolt may very well be the most devasting one and is felt by all pregnant women, not just those who become infected with the virus. Having a baby in America in 2020 is exceedingly challenging and stressful. A prominent affect of stress on the entire human reproductive process is that it causes well documented epigenetic changes in the gametes and early embryo. These epigenetics alterations continue to be expressed in future generations with serious consequences. The challenge for childbearing young persons is many- fold. As hospitals shift resources for the care of the general population with COVID -19, many are curtailing maternity care, particularly in rural communities and in Black and Brown communities. The healthcare system is overwhelmed, leaving pregnant women scrambling to find alternative places to deliver their infants as maternity services are shuttered. Often this means traveling long distances to alternative care facilities. In some areas, especially urban areas, pregnant women have sought midwives for out of hospital births, considering this alternative safer than birth in a hospital affected by the challenge of treating a serious contagious infection. Pregnant women are very fearful that they might acquire the disease in the chaotic hospital environment. But midwives are also very busy with full practice loads and are therefore unable to accommodate these requests.  

 Even though professional societies have guidelines that when followed allow a COVID-19 positive mother to room in with her new baby, in many cases, the infant is taken immediately from her. On top of this, hospitals allow only one support person for each laboring women with or without COVID-19 and in many situations even this is not allowed. In this environment pregnant women feel isolated and out of control of their experience. The fear is real that their concerns will be ignored because a busy staff might not be able to attend to all the emotional and educational needs of a women in labor. Support persons advocate for the laboring women and ease that fear. Pregnant women have a dilemma, when limited to one support persons should they choose their partner or their doula?  Numerous research studies have demonstrated that individualized, emotional support during labor is important for good birth outcomes.  Laboring women are afraid that obstetrical intervention will occur without explanation of why it was necessary or that an intervention will be occur without appropriate medical information on the part of the care giver. For instance, there is one news report of a laboring woman who had HELLP syndrome who underwent an urgent C/section without staff knowing her platelet count. Stories like this frighten pregnant women.

This fear is even greater for Black and Brown women. In fact, COVID-19 is exposing the tremendous disparities in maternity care for Black and Brown persons in the US for all to see.  Women in these communities are aware of these disparities in maternity care, and this knowledge contributes to their fear. Their knowledge of the unacceptably high maternal mortality for non-white women is a realistic fear. We wrote a Campion Fund blog posted December 23, 2019 regarding the high maternal mortality in the US. A quick update to this blog: Black maternal mortality is now reported to be 40.8/100,000 live births, and for Native Americans it is 27.7/100,000 live births. Compared to 17.4/100,000 for whites this is inexcusable. But here is the thing, even the white maternal mortality is unacceptable when compared to that of other countries.- in the UK- 9.2/100,000; in Germany- 9.0/100,00 and in Finland 3.8/100,000. In terms of maternity care, our country is a third-world country. Besides death, there are many times when childbearing women survive an episode that brings them very close to death: the “near misses” reported in obstetrical literature. No wonder pregnant women, especially Black and Brown women in the US are frightened of childbearing in 2020!

COVID-19 has disproportionately impacted all people Black and Brown communities and low income, low resource areas in general which only adds to the difficulties of pregnancy and birth in these communities. There is a tremendous disparity in pregnancy outcomes between rich and poor and this existed prior to COVID-19. COVID-19 has made this disparity worse. Persons in these communities live in crowded housing, work at low paying but essential jobs that expose then to many other persons, some who may have the virus. They lack access to health facilities. For instance, in Washington, DC, in Wards 7 and 8 which are majority Black neighborhoods there are no maternity facilities.

While many professional societies recommend utilizing telehealth for some prenatal visits, this technology does not work for persons who do not have access to computers and even if they did, they might lack the privacy with in their households where they can have confidential conversations with health providers. Subtle signs of pregnancy complications such as increased lower extremity edema might not be noticed in a telehealth visit. Not every pregnant woman would have the equipment to take their own blood pressure. In many such communities, women face provider bias. Professional staff might call pregnant women “non-compliant” or “difficult” without considering their social and economic circumstances. It is possible that a person might miss a prenatal visit because she lacks the money to pay for a bus or subway ride. That mode of transportation is a problem because it exposes a person to people who may have COVID-19 or be asymptomatic carriers of the virus. A pregnant or postpartum woman may arrive at the health facility late through no fault of her own only to be told she cannot be seen that day. Health providers can be rude, indifferent or racially insensitive. In the US nearly one-half of all births are covered by Medicaid. Medicaid in some states does not pay for all needed obstetrical care and it pays for only 60 days of postpartum care. Postpartum depression is a serious condition and  occurs a few weeks to 12 months after birth and may last 3-6 months.  Without access to care because of lack of Medicaid, this serious condition may not be noticed and treated. It can lead to death of the women as well as her infant. These challenges are real and they increase the pregnant mother’s stress, stress that leads to pregnancy complications, and to epigenetic changes in their offspring. No wonder women are frightened of childbearing in 2020! No wonder Black and Brown women are even more frightened!

Recently, I have been reading a number of articles in the medical literature of reports from State Maternal Mortality Reviews. I am seriously appalled by what I read. So many of the deaths are preventable. Pregnant people are “falling through the cracks” due to misdiagnosis, failure to notice well known complications before it is too late, lack of experience and proper education and current knowledge of their providers. I am sickened by what I read. How can this happen? How can a provider miss important information and perform a Cesarean Section without knowing the platelet count of a woman with severe preeclampsia (high blood pressure during pregnancy with liver involvement which can lead to decreased platelets) ? These failures occur for white and non-white, rich and poor alike, but they are more pronounced for non-white, and poor women. COVID-19 has exacerbated these problems and caused increase fear among women concerning childbirth in the US now.

We have work to do. We cannot fail. COVID-19 has made health care disparities worse. We need to expand heath care insurance , including Medicaid for pregnancy, birth and postpartum periods. We need to reorder our priorities so that maternity services are available to all. We need to increase the number of health care providers- nurses, midwives, physicians who will care for all our pregnant women in all our communities, rich, poor, urban, rural , suburban.  We need to rethink how we provide care. If we as a nation fail, we will pay a price in terms of the economic cost of children without a mother and the social problems that can occur, the price of epigenetic causes of adult disease in children due to the stress their mothers had. Society pays for these conditions in the long run in many ways.  In DC’s Ward 5,  in the northeast part of our nation’s capital and predominately a Black community, the Family Health and Birth Center Community of Hope exists as a model of how we might improve our maternity care and ensure outstanding outcomes and reduce maternal mortality. This is an excellent model for what can be done. We cannot fail to improve and reimagine US maternity care.

Selected References:

Breslin N, Baptiste C, Gyamfi-Bannerman C, et al. COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM 2020 [Epub ahead of print].

CDC Cases, Data and Surveillance, Data on COVID-19 during pregnancy, September 3, 2020.

Center for Infectious Disease Research and Policy CIDRAP News, May 27, 2020. 

Glass K. The pandemic’s mental health impact is dangerous for new moms. Especially black moms. The Washington Post. June 10, 2020.

Lemke MK and Brown KK. Syndemic perspectives to guide Black maternal health research and prevention during the COVID-10 pandemic. Matern Child Health J. 2020 21:1-6.

Metz TT, Collier C, Hollier L. Maternal mortality from Coronavirus Disease 2019 (COVID-19) in the United States. Obstet Gynecol 2020 136: 313-6.

Minkoff H. You don’t have to be infected to suffer: COVID-19 and racial disparities in severe maternal morbidity and mortality. Am J Perinatol 2020 37: 1052-4.