This document is part of a series of discussion notes addressing fundamental questions about COVID-19 and response strategies. These documents are based on the best scientific information available and may be updated as new information comes to light.
Written by Elena Marbán Castro, Cristina Enguita Fernàndez, Clara Pons Durán, Azucena Bardají, Laura García, Raquel González and Clara Menéndez, all of them from the Maternal, Child and Reproductive Health Initiative at ISGlobal, this document addresses how pregnancy is a factor of vulnerability against COVID-19.
Since the start of the COVID-19 pandemic, pregnant women have been deemed a “vulnerable population” due to their morbidity and mortality in previous epidemics involving other coronaviruses, namely SARS (2003) and MERS (2013). Physiological changes in lung function and adaptation of the immune system during pregnancy may also increase susceptibility to and clinical severity of COVID-19 pneumonia. Moreover, pneumonia arising from any infectious aetiology is among the leading causes of maternal mortality.
The Pan American Health Organisation (PAHO) has warned that pregnant women are at increased risk of developing severe forms of COVID-19 and of being admitted to intensive care units compared to non-pregnant women. They are also at higher risk of requiring mechanical ventilation and of experiencing disease-related adverse effects arising from cardiovascular changes during pregnancy.
Moreover, there is increasing evidence of mother-to-child transmission of the virus. Although it happens only rarely, it has been observed that foetuses can become infected with SARS-CoV-2, especially during the last months of pregnancy.
What Care Should Pregnant Women Receive?
- Screening pregnant women for SARS-CoV-2 early in pregnancy (during prenatal visits) could be beneficial, as it would improve clinical management and prevent possible complications of infection.
- Numerous international obstetric societies recommend screening for SARS-CoV-2 before delivery or on admission to hospital for any other reason, with the aim of reducing the risk of transmission to health care staff as well as performing epidemiological surveillance and prioritising health care resources.
- When availability of diagnostic tests is limited, pregnant women should be prioritised as an at-risk group.
The Importance of Quality Information
ISGlobal’s Maternal, Child and Reproductive Health Initiative is leading the only clinical trial of a drug to prevent SARS-CoV-2 infection and COVID-19 in pregnant women (COVID-Preg). As a part of this clinical trial, a qualitative study was conducted by carrying out in-depth interviews with 24 pregnant women about their knowledge, perceptions and experiences of COVID-19
- Over the course of the pandemic, the pregnant women interviewed have received contradictory information. Health workers, official sources and the media need to improve their communication with pregnant women regarding the effects of COVID-19 during pregnancy.
- Many interviewees have experienced anxiety and fear of infection, which can lead to isolation—even from partners and close family members—and less interaction with the health system, given that in-person visits to health centres have been scaled back. Better communication could help to prevent mental health problems, anxiety, insomnia, etc.
- Many women say they had to give birth alone and that various group activities, including childbirth education classes and breastfeeding support groups, have been cancelled. During the pandemic, pregnant women should be allowed to be accompanied during all prenatal visits and during childbirth, as long as safety measures are followed. During strict lockdown periods, childbirth-education classes, breastfeeding support groups, etc., should be conducted virtually.
Scaling Back In-Person Prenatal Visits and Access to Reproductive Health Programmes
- The pandemic’s medium- and long-term consequences on maternal and child health, brought about by the scaling back of in-person prenatal visits, are not yet well understood. In low-income countries, for example, prenatal visits have not been replaced by telephone consultations, resulting in potential negative consequences for prenatal and child health. In Spain, as in other high-income countries, most obstetric visits have been replaced by telephone consultations; however, access to sexual and reproductive health services has been scaled back.
- In relation to reproductive health during the pandemic, there are two distinct scenarios in different countries and regions throughout the world. Low-income countries have seen an increase in unwanted pregnancies—including adolescent pregnancies—due to reduced access to family-planning services and an increase in gender-based violence. It has been predicted that 7 million unintended pregnancies will occur during the COVID-19 pandemic, accompanied by an increase in maternal mortality associated with unsafe abortions as well as girls and adolescents dropping out of school, among other consequences.
In contrast, high-income countries have seen a decline in birth rates due to a decrease in the use of assisted reproduction processes (which account for 9% of all pregnancies in Spain), as a result of financial hardship and changes in families’ reproductive priorities, among other reasons.
What Can Be Done to Improve the Health of Pregnant Women During COVID-19?
- Promote the inclusion of pregnant women in clinical trials of pharmaceuticals (including vaccines) for the treatment and prevention of COVID-19, since they are often excluded from said trials.
- Answer key questions that are important for improving the management and prevention of infection: How common is mother-to-child transmission of SARS-CoV-2? What are the manifestations of COVID-19 in pregnant women and newborns?
- Conduct qualitative studies to understand the effects of COVID-19 on emotional health as well as the social impact of the infection during pregnancy.
In public health:
- Establish COVID-19 prevention guidelines for pregnant women and their milieu (partner, family, etc.) to prevent infection.
- Prioritise pregnant women for COVID-19 diagnostic testing.
- Record pregnancy status in contact tracing for early identification of pregnant women exposed to the virus.
- Depending on the level of community spread, adapt the frequency of in-person prenatal visits and complement them with virtual follow-up care throughout pregnancy.
- As long as hygiene and safety measures are followed, we recommend that pregnant women be allowed to be accompanied by their partner or other family members during prenatal visits and childbirth.
- Enable childbirth education classes and breastfeeding support groups to keep meeting virtually in order to maintain the benefit of sharing experiences and feeling supported.
- Adapt lockdown, reopening and other public health measures to take pregnant women into account as a vulnerable group.
- Allow pregnant women priority access to indoor environments that may pose an increased risk of infection (e.g. supermarkets, public transport and administrative institutions) to minimise their contacts.
- Prioritise women’s mental health during pregnancy to minimise the negative effects of pandemic-related measures.
- To prevent unwanted pregnancies, guarantee access to family-planning methods, emergency contraception and voluntary termination of pregnancy, even during the pandemic.
- Publish news on COVID-19 and pregnancy to improve knowledge of how the disease affects reproductive health in the general population and to ensure that women have an appropriate perception of risk that reflects reality.
- Increase the dissemination of COVID-19-related news of interest to specific groups such as pregnant women, particular age brackets, etc.
- Promote open dialogue by airing interviews with experts in various fields—obstetrics, paediatrics, public health, psychology, anthropology, etc.—so that families can have access to quality information.