HealthManagement, Volume 20 - Issue 4, 2020

The Impact of COVID-19 Pandemic on Women´s Health and Pregnancy Care

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Amid the COVID-19 pandemic women are often deprived of necessary health care. The research on women’s health in this context is scarce and might often be compromised, but also widely distributed in the media. The International Academy of Perinatal Medicine, therefore, is adamant to uphold the best scientific standards.


Without a doubt, COVID-19 has already changed the world on the magnitude never seen before. The invisible devil has affected the life of virtually every single human being on the planet. Worldwide, the virus has infected more than


5.6 million people and killed over 350,000 as of May 28. The real numbers of COVID-19 infections are much higher due to the lack of testing capacity and underreporting. The invisible enemy has locked down entire countries, grounded most of the air traffic, paralysed the industry and affected normal life in every sense. COVID-19 is, although dangerous, a very fair virus choosing not only poor, homeless, or old people with chronic diseases but also prime ministers, crown princes, celebrities and wealthy people. It is omnipresent, ready to ambush anywhere, from the glass palaces of New York to remote villages in the African deserts. One of the most vulnerable groups to cope with the consequences of the COVID-19 pandemic are women, particularly pregnant ones.


Lessons Learned and Results Reporting

The data about the outcome of pregnancies with COVID-19 infection are scarce, and the results of the current studies are inconsistent and obtained mostly from middle or low-income countries with different healthcare systems, unequal access to pregnancy care and pregnancy surveillance. The knowledge gained from previous human coronavirus outbreaks, namely severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) as well as Ebola virus disease (EVD), suggests that pregnant women and their foetuses may be particularly susceptible to poor outcomes (Sochas et al. 2017). Admission to intensive care is common, and a case fatality rate of up to 35% has been documented.


The prevalence of the COVID-19 infection during pregnancy in the epidemic areas is largely unknown despite of two existing systematic reviews. Data from only 108 pregnancies between December 8, 2019 and April 1, 2020, have been summarised in a recent systematic review (Zaigham and Andersson 2020). Three maternal intensive care unit admissions were recorded, but no maternal deaths. There was one neonatal death and six admissions to an intensive care unit. Although it seems that severe pregnancy and neonatal complications during COVID-19 pandemic are mostly due to the premature birth and caesarean delivery complications (as the predominant delivery mode), the latest systematic review that included a total of 324 pregnant women with COVID-19 reported seven maternal deaths (Juan 2020).


While most of the reported cases focussed specifically on the maternal outcomes and possible vertical transmission, less attention has been paid to foetus as a patient in such pregnancies. For example, the majority of publications are systematically lacking data on antenatal steroid use for the foetal lung maturation and foetal neuroprotection in the imminent premature birth, which are the cornerstones of the antenatal interventions for the improvement of outcomes in premature delivery frequently associated with COVID-19 infection. Also, changes in existing guidelines concerning antenatal interventions caused by COVID-19 pandemic are more rule than exception, with scarce or no evidence-based approach to such adjustments (Stefanovic 2020).


During the EVD outbreak in Liberia, overall monthly reporting from health facilities plunged by 43%, access to antenatal care declined by 50%, and reported deliveries fell by one third. Reported deliveries by skilled attendants and caesarean sections declined by 32% and 60%, respectively. Facility-based deliveries dropped by 35%, and reported community deliveries fell by 47% (Shannon et al. 2017). The study showed a substantial gap in reported access to antenatal care and deliveries. There was a severe decline in institutional deliveries performed. This was especially evident in C-sections and deliveries by skilled attendants. The monthly reports submitted by health facilities dropped substantially during the outbreak. Additionally, a recent assessment evaluated how the Ebola outbreak in the Democratic Republic of the Congo, which peaked between 2018 and 2019, impacted sexual and reproductive health services there (International Rescue Committee 2020). The assessment made several recommendations on how to maintain these services in the midst of outbreaks, which we can draw from now.


During the Ebola outbreak, barriers, including cost of healthcare and physical inaccessibility of healthcare facilities, delayed or prevented 90% of rural and 59% of urban pregnant women from receiving health care in Sierra Leone, the country with the world’s highest estimated maternal mortality. The vast majority of women did seek assistance in labour, but many did not subsequently receive it. This suggests that help was unavailable to a substantial proportion of women, particularly in rural areas (Elston et al. 2020). This decrease in utilisation of life-saving health services translates, in Sierra Leone alone, to 3,600 additional maternal, neonatal and stillbirth deaths in the year 2014-2015 under the most conservative scenario (Sochas et al. 2017). Learning from West Africa’s large, multicountry EVD outbreak of 2014-2016 tells us that there were significant impacts on sexual and reproductive health systems, particularly in the early stages of that outbreak, largely related to health facility closures (International Rescue Committee 2020).


It should be stated that most of the scientific research on COVID-19 (also, during pregnancy) is currently being conducted in a way that would probably be completely unacceptable to serious science in any other circumstances. The research has been fast-tracked to publication and possibly without proper peer-review process, using small and often insufficiently representative samples. Numerous imperfections in the research design are being overlooked as well as many other details, which are usually taken into account. All these factors resulted in a flood of superficial research, all in a desire to get answers as fast as possible. Unfortunately, rushed and wrong answers can cause greater damage than an accurate, but slow one. An additional problem is that every single research is getting huge media attention worldwide, with an increasing number of published preprint results; results of scientific papers, which anyone can publish on prepublication platforms, without any serious scientific or professional review. Scientists will have no trouble distinguishing serious research from that with serious flaws, but journalists will have harder time making that distinction. Thus, it is realistic to expect a whole series of daily reports on various ‘scientific research results,’ which in a week or two will turn out to be wrong or unfounded. It is a shame that so much time and media space is constantly being wasted on completely unfounded reports and results. But that is one of the fundamental characteristics of this ‘infodemic’ we are experiencing.


COVID-19 and Other Women´s Health Issues

Pregnancy and labour are usually a time of joy, but can also be associated with increased anxiety as well as increased risk of wellbeing disturbances, both during pregnancy and after birth. The consequences of COVID-19 are unfortunately unequally distributed among the countries. Pregnant women in developed countries with well-organised healthcare systems suffer mostly due to the uncertainty regarding the impact of illness on mothers and newborns, and anxiety caused by the social isolation and limited number of birth companions. The struggles of pregnant women in developing countries during COVID-19 pandemic might be more existential in nature. While data are scarce, reports from several countries suggest an increase in domestic violence cases since the COVID-19 outbreak. For example, the number of such cases reported to a police station in Jingzhou, a city in Hubei Province in China, tripled in February 2020 compared to the same period in the previous year (Allen-Ebrahimian 2020). Security, health and money worries create tensions and strains accentuated by the cramped and confined living conditions of the lockdown. More than half of the world’s population was under lockdown conditions by early April.


Social isolation due to the lockdown in many countries will affect many women as significant proportion of them will (and already have) become jobless (eg, those working in services, tourism, or administration). Difficulties in seeking medical care will result in defective postpartum and post-abortion care, the access to emergency contraception will also suffer, and mental health issues will emerge (the majority of physicians and nurses taking care of COVID-19 patients are women). The magnitude of the problem will be estimated in the future.


Future Perspectives

The impact of the COVID-19 pandemic on women´s and reproductive health services needs to be considered from the outset to avoid disruption or loss of confidence in those services. Maternity and public health services should be planned well in advance to minimise delays in accessing and receiving care. When healthcare facilities are feared, they are avoided. It is essential that messages reach the women and help them and their families to seek early advice and make timely decisions. This is particularly important for women in areas of quarantine, in self-isolation, or with reduced transport options. For women who have complications during pregnancy, a late presentation can have serious consequences for the outcomes, as experiences from previous epidemics have shown.


Community members and healthcare providers should be made aware of the increased risk of social isolation and the lockdown to the complexity of women´s health issues. Women may have less contact with family and friends who may provide support and protection from violence. Additionally, violence against women can result in physical injuries and serious physical, mental, sexual and reproductive health problems, including sexually transmitted infections, HIV and unplanned pregnancies. Violence against women remains a major global public health concern and threatens women’s health during emergencies.


Suggested solutions, like social distancing and lockdowns in many areas, to help to contain the spread of the virus may affect this vulnerable population due to its inability to access healthcare facilities for routine care and medicines management. One of the solutions may be the extended use of mobile devices and tablets that has revolutionised healthcare for some of the hardest-to-reach communities across Asia, Africa and the Middle East.

It should be emphasised that the contribution of community pharmacists in managing chronic conditions and promoting medication adherence while other health personnel is battling the COVID-19 pandemic on the front line is key to easing the disease burden on health systems, particularly in developing countries. This will provide support to the call by the World Health Organization to maintain essential services in order to prevent non-COVID-19 disease burden on already strained health systems in low-income countries (Kretchy et al. 2020).


The activities of the International Academy of Perinatal Medicine have had a remarkable impact on perinatal care worldwide (Kurjak 2014). Naturally, the future depends on the role of its members because no academy can be appreciated by itself, but only by the reputation of each and all of its members. Indeed, science is a truly global activity because its very nature is global. Most of us welcomed positive globalisation process, but with the current COVID-19 pandemic we are facing the negative part of globalisation with many unpredictable developments (Kurjak 2016). In science, we do not have good and bad work. By following our principal duties, we justifiably expect that creative and visionary members of the Academy show again their intellectual power in order to defeat this global pandemic. The future relies on the past, and now it is proper time to show our own vision of the future (Kurjak 2017).


Our Academy has both the responsibility and the privilege to conduct scientific research on the impact of the COVID-19 pandemic on maternal, foetal and neonatal health. Studies recently published in prestigious journals are, unfortunately, of very suspicious quality, and the results of the studies not only give little additional information to healthcare providers but also cause confusion with inappropriate adjustments of the antenatal care without scientific background.


Without any doubt, this will open the way to new visionary solutions, and one of them will be deep analysis of what the science in perinatal medicine assessed and recommended to perinatal world (Kurjak et al. 2008; Kurjak and Dudenhausen 2007). In a world of rapid advances in scientific discovery, with an unprecedented insight and understanding of human development, which are reshaping the meaning and value of human existence, it is clear that we all are living in the global setting of computer-based video conferencing and satellite transmission. Therefore, a new idea born in a small global village will soon be available in every corner of the world.


We are lucky to have our official Journal of Perinatal Medicine, and Academy Corner in it dedicated to the wise thoughts of the Academy members. What should we really offer through the journal and its Academy Corner to our readers in this complicated part of our lives (Kurjak et al. 2010)?


The principle of the Academy should not be ‘any information is better than none.’ The information should be feasible, usable and implementable and proven according to the best scientific principles. It may be that the research of the Academy members will not be the first to be published, but we certainly aim that the scientific evidence published by the Academy will be fast, reliable and implementable. 


Key Points

  • With the COVID-19 pandemic, women are one of the most vulnerable groups, not receiving necessary care and experiencing additional negative impacts.
  • The data on women’s health with COVID-19 infection are scarce and inconsistent, but previous infectious disease outbreaks suggest increased likelihood of poor outcomes.
  • As a result of COVID-19 restrictions, women may not only receive insufficient health care but also face difficulties such as financial insecurity, domestic violence and mental health issues.
  • The consequences of these will only transpire in the future, and currently various support options should be put in place (eg, telehealth services).
  • Most of the relevant scientific research would not count for ‘serious science’ under normal circumstances, but, unfortunately, it receives much media attention.
  • The International Academy of Perinatal Medicine reiterates its adherence to solid scientific research principles and encourages its members to provide only the best scientific evidence.


References:

Allen-Ebrahimian B (2020) China’s Domestic Violence Epidemic. Axios. Available from iii.hm/13et


Elston JWT et al. (2020) Maternal health after Ebola: unmet needs and barriers to healthcare in rural Sierra Leone. Health Policy and Planning, 35(1):78-90. Available from iii.hm/13eu

International Rescue Committee (2020) Not All That Bleeds is Ebola – how the DRC outbreak impacts reproductive health. Available from iii.hm/13ev


Juan J et al. (2020) Effects of Coronavirus Disease 2019 (COVID-19) on Maternal, Perinatal and Neonatal Outcomes: A Systematic Review. Ultrasound Obstet Gynecol, 55(5):586-592 [Epub ahead of print]. Available from iii.hm/13ex


Kretchy IA et al. (2020) Medication management and adherence during the COVID-19 pandemic: Perspectives and experiences from low-and middle-income countries. Res Social Adm Pharm [Epub ahead of print]. Available from iii.hm/13ey


Kurjak A (2014) Global education in perinatal medicine: will the bureaucracy or smartocracy prevail? (Academy Corner). J Perinat Med, 42(3):269-271


Kurjak A (2016) First 10 years of the International Academy of Perinatal Medicine – which lessons we have learned and what are future challenges (Academy Corner). J Perinat Med, 44(7):733-735


Kurjak A et al. (2008) Editorial: Does globalization and change demand a different kind of perinatal research? J Perinat Med, 36:273-275


Kurjak A et al. (2010) Globalization and perinatal medicine – How do we respond? The Journal of Maternal-Fetal and Neonatal Medicine, 23(4):286-296


Kurjak A, Dudenhausen JW (2007) Editorial: Poverty and perinatal health. J Perinat Med, 35:263-265


Kurjak A (2017) Editorial: 3D/4D Sonography. J Perinat Med, 45(6):639-641


Shannon FQ et al. (2017) Effects of the 2014 Ebola outbreak on antenatal care and delivery outcomes in Liberia: a nationwide analysis. Public Health Action, 7(Suppl 1): S88–S93.


Sochas L et al. (2017) Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. Health Policy and Planning, 32(3):iii32–iii39


Stefanovic V (2020) COVID-19 infection during pregnancy: fetus as a patient deserves more attention. J Perinat Med [Epub ahead of print]. Available from iii.hm/13ez


Zaigham M, Andersson O (2020) Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies. Acta Obstet Gynecol Scand [Epub ahead of print]. Available from iii.hm/13f0





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