Covid Babies

How pandemic health measures undermined pregnancy, birth and early parenting

Amy Brown

• Publisher: Pinter & Martin Limited
• Year: 2021
• eBook ISBN: 9781780667638
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

As the Covid-19 pandemic took hold, pregnancy and maternity services underwent a rapid transformation in an attempt to deal with transmission of the virus and the growing pressure on healthcare services. In a climate of fear, and with many unknowns about the virus and the risks to pregnant women and their babies, restrictions and hastily implemented policies often overrode years of work to improve maternity care, with devastating consequences for new families.

Covid Babies: how pandemic health measures undermined pregnancy, birth and early parenting considers how policies put in place to protect us from the immediate threat of the virus ultimately had the unintended consequence of harming many who needed maternity and postnatal care. It highlights how hard-won gains, even when supported by overwhelming evidence, can be lost at the drop of a hat in a crisis.

By learning the lessons of the pandemic – through close examination of the evidence base that is now emerging – Amy Brown shows how we can begin to move forward and unravel what has gone wrong. This is no easy task when our health services continue to face significant challenges, but one that is necessary to ensure the health and wellbeing of our new families and those who care for them.

1

PREGNANCY DURING A PANDEMIC

PREGNANCY DURING A PANDEMIC

THE IMPACT UPON PHYSICAL AND MENTAL HEALTH

Experiences of pregnancy have been seriously affected by the pandemic. Expectant parents were faced with two main fears: would the virus affect the health and wellbeing of pregnant women and babies? And how would lockdowns and social distancing affect antenatal care? Understandably anxieties ran high, not helped by the media presenting manipulative and confusing messages about the risks during pregnancy and how care might be affected.

We now know that pregnant women as a group are at increased risk of complications if they become unwell with Covid-19. Protecting them and those who care for them was and still is important. However, as we will see in more detail later, there is a big difference between being at ‘increased risk’, and ‘definitive harm’ being caused to all pregnant women. Arguably the individual risk or likelihood of being seriously affected in terms of physical health was actually relatively low for many women without underlying health issues, but the negative psychological impact of changes to care was almost universal. And that’s before we even consider the harm of fear-based messaging in the media that led some families to feel very unsafe indeed. There is a fine balance between protecting pregnant women and babies from the virus, and ensuring they receive the high-quality antenatal care we touched on in the introduction. Unfortunately, throughout the pandemic the balance has often been off.

What are the physical risks of Covid for pregnant women?

The evidence about whether pregnant women are at greater physical risk has changed over time. During the period when we were first going into lockdown, in March 2020, messaging was chaotic. There was a lack of data about the specific impact of Covid-19, but we knew from previous outbreaks of similar viruses, such as SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome), that pregnant women, especially those in the third trimester, might be at increased risk due to alterations in immune system and cardiovascular function during pregnancy.¹ On the one hand there was talk of pregnant women needing to ‘shield’ (remain at home, avoiding all contact with others). And on the other hand we had guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) published in late March 2020, which raised awareness of the potential risk of increased susceptibility but noted that at the time of publication there had been no cases of pregnant women dying from the disease.²

Of course, over time the number of infections increased and we sadly did have cases of pregnant women becoming very seriously unwell and dying of the virus. It is really difficult to try and track and measure outcomes for a disease that has only relatively recently emerged and is still ongoing, especially at the start of a pandemic when case numbers are relatively low. For research studies to have sufficient numbers to be statistically accurate, you need sufficient numbers of pregnant women experiencing the illness and complications. Therefore at the start of the pandemic we desperately needed data, but had to rely on case studies, as many pregnant women were (thankfully!) protected from catching the virus due to the lockdown.

But science doesn’t ever (or rather shouldn’t ever) base conclusions and policies on just one study, or even several, especially not case studies of individual women. It is the broader picture of research studies (taking into account how they were done and who was involved, and all the inevitable limitations) and how they fit together that should inform our decisions. Unfortunately, however, the news media searched for and manipulated anything they could spin to create more fear, in turn exacerbating the confusion around whether pregnant women were more at risk from the virus and its complications. A ‘breaking news story’ of a pregnant woman seriously ill or dying from Covid-19 infection is of course devastating, but it is not necessarily an indication that all pregnant women are at high risk. In reality, journalists and reporters know this, but it was disregarded in the pursuit of media market share.

Data soon began to accumulate that confirmed that although pregnant women were not at greater risk of developing Covid-19 infection in the first place, if they did catch the virus they were at risk of more serious complications as a result of the illness,³ particularly during their third trimester.⁴ Although most pregnant women who contracted Covid-19 only had mild symptoms (that probably didn’t feel very mild, particularly in later pregnancy), some pregnant women did sadly die as a result of the virus due to complications exacerbated by the immune and cardiovascular changes of pregnancy. However, notably this direct impact of the infection was not the only cause of some maternal deaths.

In the UK data on maternal mortality rates are published in the MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) report.⁵ Two reports have been published since the start of the pandemic, examining maternal deaths as a consequence of Covid-19. The first was a rapid review examining deaths from 1 March–31 May 2020. It included the deaths of 10 women who died with Covid-19. Seven deaths were directly due to the virus (six from cardio-respiratory disease and one from a blood clot in the brain). Two deaths were from unrelated causes, but the women were infected with Covid-19. Data for one woman was unclear as no post-mortem had been carried out, but her death was thought to be due to Covid-19. All were in the last trimester of pregnancy when they became infected. Ninety per cent were from Black, Asian and minority ethnic (BAME) groups including Black (30%), Asian (50%) and Chinese (10%) backgrounds. For context, during the same period six pregnant or postnatal women died from other common causes of maternal death, including four from suicide and two from domestic abuse.

At the end of the first report the authors noted that ‘It is reassuring that pregnant and postpartum women do not appear to be at higher risk of severe Covid-19 than non-pregnant women’. However, in a second report including data from June 2020–March 2021 it was noted that the second wave of the virus brought a higher rate of infection and new variants of concern.⁶ With more virus circulating, and therefore more likelihood of coming into contact with it, the data started to show that pregnant women were at a greater risk of Covid complications than non-pregnant women of reproductive age. It is important to remember that the overall individual risk, particularly to those without significant health complications, was still relatively low – but it had increased.

Overall, the second MBRRACE report identified 17 women who had died as a consequence of Covid-19 in the UK. To put these figures in the context of absolute risk, during the 10-month period that the report covers, approximately 587,700 women gave birth in the UK, giving an estimated maternal mortality rate of 2.4 in 100,000 births. It should be noted that this risk applies across all pregnant women whether they caught Covid-19 or not, and is not the risk of mortality if unwell with the virus. Also, the authors caution that MBRRACE maternal mortality estimations are usually based on figures over a three-year period to allow for any natural variations, so these data are not directly comparable. But for context there are approximately 70 maternal deaths during pregnancy or in the first six weeks postpartum every year in the UK. This data also gives averaged figures across all mothers. Risk for mothers from BAME groups, as we shall see below, is higher.

Ten of the seventeen women died from causes directly related to Covid-19, including cardio-respiratory complications (n=9) and thrombotic complications (n=1). Four women were positive for Covid at the time of their death but died from unrelated causes. However, three women were deemed to have died as a result of altered care, or engagement with care, due to the pandemic. For example, one woman was admitted to hospital with Covid-19. Her symptoms (e.g. fever) were believed to be due to Covid and she was placed in a bed and not observed for another 6.5 hours. It turned out that although she was infected with Covid, she had actually experienced a missed miscarriage and died from sepsis due to an intrauterine infection. Her symptoms of sepsis were overlooked due to the focus on the symptoms and diagnosis of Covid-19 infection.

The report examined the care the 10 women who died directly from their Covid infection received. Just one woman was considered to have received good care. Two were considered to have received care that could have been improved, but was unlikely to have prevented their death. However, for seven women improvements could have been made to their care which could have led to a ‘difference in outcome’, or in other words quite possibly have saved their lives.

Of the 10 women who died as a direct result of Covid infection, half were in their third trimester. In terms of risk factors 80% were overweight or obese, 60% were from Black, Asian and minority ethnic groups and 50% had a pre-existing mental health condition. However, no woman had a pre-existing physical health condition such as diabetes, hypertension or cardiac disease. It is unclear from the report how many pregnant women overall who gave birth during the report period were from BAME groups. Given that BAME groups make up approximately 13% of the UK population and approximately 587,000 women gave birth, we could assume that around 82,000 BAME women gave birth during that period. If six women died directly of Covid-19, this gives a rate of death of 7.3 in 100,000. Conversely, if four White women died directly of Covid-19 this gives a rate of death of 0.8 in 100,000, a shocking difference in the maternal death rate by ethnic group. Please note that these are my estimates and are not directly taken from the MBRRACE report. However, the difference in death rate is clear and we will come back to this later.

In terms of hospital admissions for Covid-19 among pregnant women, a national population-based survey including all 194 obstetric units in the UK collected data on admissions and outcomes.⁷ During a six-week period at the start of the pandemic, 427 pregnant women were admitted to hospital, which represented around 4.9 in every 1,000 women who gave birth during that period. Again, that figure is based on all births and not just those who had Covid-19. Additionally, the authors note that not all were seriously unwell; an increased cautionary tendency to admit pregnant women who were unwell may have inflated these figures. Most women who were admitted (81%) were in their third trimester – a figure that has been supported in other studies.⁸

In terms of who was admitted, 69% were overweight or obese, and 34% had pre-existing conditions such as diabetes or cardiac disease. Obese and overweight pregnant women have been more likely to be admitted to hospital with Covid-19 during pregnancy across many studies, as have those who are overweight or obese in the general population. It is likely that the association of obesity with other chronic illnesses, insulin resistance and inflammation, plays a role in exacerbating the impact of the virus.⁹

Additionally, as with the previous study, those from BAME groups were overrepresented. Here 56% were from BAME groups when BAME groups make up 13% of the general population in the UK. This can partly be explained by physiological factors. Pregnant women from BAME groups are more likely to have genetic risk factors or health comorbidities that place them at increased risk from viruses such as Covid-19. Other contributors include being more likely to live in densely populated or deprived areas where infection risk is higher.¹⁰

However, a crucial factor highlighted in many commentaries is the structural and institutional racism that places individuals at greater risk of health complications.¹¹ It is now established that women from BAME groups are at a greater risk of complications in the perinatal period even when we are not experiencing a global pandemic.¹² Increasingly research shows that women from BAME groups do not access the same level of support from health services during the antenatal and postnatal periods. This isn’t due to a lack of awareness of services or their potential benefits, but rather due to racial inequalities in the suitability and accessibility of services currently offered, which mean that women avoid care or miss out on being cared for. Research has highlighted how a lack of cultural sensitivity, overt and covert issues of racism and a perceived lack of focus on individual needs can lead to vastly different care experiences.¹³ Urgent reviews into this issue, specifically in relation to Covid-19, are needed to ensure equity in care.

Admission into hospital is not the same as admission into critical care. In the hospital admission study above 10% of women admitted to hospital needed critical care (n=41).⁷ This represents a critical care rate of 1 in 2,400 women who gave birth during that period (i.e. across the population, not across those who were infected). All these women needed respiratory support, but just one woman was intubated. Sadly, 1% of hospitalised women died, this represents 1 in 18,000 women who gave birth during that six-week period. When this was examined according to the admission and mortality rates at the time, no difference in risk of critical care admission or death was seen between pregnant women with Covid-19 infection and rates in the general population of women of reproductive age. Of course every death is devastating to a family, especially when it seems that the death may have been preventable. But keeping this in context, in terms of the extent to which pregnant women ‘needed’ to be anxious, is important due to the effect of anxiety on other health-seeking behaviour. Hold this thought as we’ll return to it in more detail later in this chapter.

The previous study was based on data from early on in the pandemic (1 March–14 April 2020) when cases and transmission were relatively low. More globally, a review paper updated in September 2020 analysed data from 192 studies including 67,271 women who attended or were admitted to hospital for any reason, including confirmed or suspe...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Introduction
• 1. Pregnancy during a pandemic – the impact upon physical and mental health
• 2. How did the pandemic affect care during birth?
• 3. Giving birth while positive for Covid-19
• 4. Experiencing pregnancy complications during the pandemic
• 5. Postnatal care during the pandemic
• 6. Experiences of infant feeding during the pandemic
• 7. Pandemic postnatal mental health
• 8. The impact of lockdown on infant health and development
• 9. Vaccination chaos for pregnant and breastfeeding women
• 10. Moving forward
• If you’re reading this as a new parent
• References
• Index