Abstract
The Covid-19 epidemic directly affects reproductive and postnatal health through illness but also indirectly affects reproduction and perinatal healthcare via changes in healthcare delivery, socialist programs, and socioeconomic situations. COVID-19’s direct and indirect effects on maternity care are inextricably linked. To examine this critical subject, the scope of this research has been limited. Pregnant women with symptomatic COVID-19 may have more severe consequences than non-pregnant women. Internal transfer and transmission from mother to baby through breastfeeding are improbable during labor and delivery. Contrary to popular belief, the procedures used to monitor COVID-19-positive individuals throughout labor, delivery, and breastfeeding differ. Prenatal care appointments have decreased, the public health system has grown overloaded, and possibly destructive policies are being undertaken in low – and high nations without supporting facts. As per World Health, COVID-19 has a significant social and economic effect on maternal health. Several nations have reported a high prevalence of father mental health disorders, such as severe depression and anxiety, during the pandemic. This certainly indicates an increase in worries, despite little evidence indicating a significant shift in this direction. Domestic violence seems to be increasing in occurrence. Following the epidemic, working moms saw more difficulties than their male colleagues in completing their increased childcare duties. As a result, more money for epidemiologic research should be provided, health and community assistance should not be decreased; and greater attention should be paid to maternity care throughout the pandemic.
Keywords: Mental health, COVId-19, prenatal care, postnatal care, C-section.
Introduction
The term “maternal health” refers to the health and well-being of a woman during pregnancy, childbirth, and the postmortem period. Each stage should be a positive experience, ensuring that women and their unborn children achieve their maximum potential for health and well-being; however, this was not the case during the COVID-19 outbreak. Maternal health is directly affected by the Covid-19 outbreak, which is connected to the interaction between maternity care and illness. After being discovered in Wuhan, China, towards the end of 2019, the COVID-19 virus spread quickly over the globe, infecting millions of people in the process. As a result of the disease’s serious health effects on men rather than women, there is a major worry that the disease will hugely disproportionately burden women in both an economic and social sense if the virus occurs. While data on intimate relations and acute respiratory syndrome coronavirus mortality recommends that the disease has much more severe health results for males than females, the disease’s social and economic consequences for women are not well understood. Another question of considerable relevance is whether pregnant women are more vulnerable to SARS-CoV-2 infections or suffer more severe sickness outcomes due to these illnesses.
Aside from direct transmission, the impact of the infection and global epidemic tactics on the healthcare system, society, and the world economy may impact maternal and baby health and the overall health of the population. Especially sensitive to concerns such as domestic abuse, expectant mothers and new moms are a particular demographic with specific physical and mental healthcare demands. They are also a particularly vulnerable population to sexual assault. After everything is said and done, the COVID-19 pandemic will probably have a context-specific effect that will change based on several country-specific circumstances.
Studies published before or shortly after policies are established may not include all of the most important findings, and published studies before or shortly after regulations are enacted may only include some of the most important findings. The intention of this needs assessment is to synthesize scientific literature on both the direct consequences of contracting COVID-19 while giving birth and the unintended effects of the flu epidemic on pregnant mothers while also taking into account the numerous ways in which consolidation and prevention proposed measures have disrupted pregnant women’s and mothers’ daily lives. The literature was evaluated for the direct repercussions of COVID-19 infection during childbirth and the indirect effects of the communicable illness on pregnant women and mothers.
Method
This scoping review used Arksey and O’Malley’s approach for mapping the current study on the indirect effects of Coronavirus on maternity care, comprising the following steps.
- Pertinent Sorts of Evidence
The search comprised works printed in English between January 2020 and September 2020. Moreover, the search approach was based on the Antenatal Care Task Buzz’s algorithm, a fortnightly e-newsletter that summarizes current maternal health research. We conducted manual searches in PubMed using MeSH keywords, as well as more thorough searches utilizing the phrases Coronavirus in conjunction with the terms “pregnancy,” “related to pregnancy,” “women,” “reproductive,” social, “economic,” “direct,” and “indirect.” Using similar criteria, online databases were combed for grey content, such as news articles and unpublished working papers. This scoping study sought to capture rapidly developing material on time, including problems that still need to be explored in well-funded epidemiological research. The snowball strategy of reviewing sources’ bibliographies was used to supplement mentioned content in individual articles.
- Selection of Studies
The research was included if written during the period specified above and focused on the indirect or direct impacts of the COVID-19 outbreak on maternal well-being. Although the search criteria did not specifically address neonatal health, papers on subjects important to both groups were included if retrieved. The following types of papers were included: published studies, case studies, qualitative investigations, systematic and comprehensive reviews, as well as meta-analyses. Because several papers incorporated systematic or exploratory concepts, there was some repetition in the data used to generate the publications. The article, with a more detailed explanation, was utilized to create the data charts. Sources were omitted if they included just suggestions for more research. Predictive research was omitted if it comprised only hypotheses based on previous epidemics but was allowed if quantitative methodologies were used. We included news stories, dissertations, and other grey literature with measurable evidence. After reading whole texts and integrating pertinent material, the literature was thematically arranged. All four writers talked and agreed on themes. The evaluation eliminated themes that represented possible COVID-19 effects but lacked quantitative data.
- Effects on Pregnancy Directly.
Pregnancy induces significant physiological and immunological changes in women, which are necessary to feed and protect the developing infant. Due to these modifications, pregnant mothers and their fetuses may be at increased risk of chronic virus infection. Patients with COVID-19 who are pregnant do not seem to have more severe sickness symptoms than non-pregnant females. The vast majority of cases in expectant mothers are asymptomatic or very mildly symptomatic. According to studies, pregnant women with COVID-19 are substantially more likely to admit to the critical care unit, be intubated, need ventilators, and die than other pregnant women.
Preterm delivery was the most often reported adverse outcome; an increased frequency of lower birth weight and cesarean delivery were also found. Other obstetric problems and outcomes were uncommon but noticeable, counting maternal mortality, stillbirth, preeclampsia, miscarriage, fetal development limit, coagulopathy, and preterm rupture of membranes. According to research conducted in London, stillbirths would become more prevalent due to the effects of the pandemic.
Results
Ninety-six publications were identified throughout the search, of which nine would be included. It has been shown that pregnant women are more likely than non-pregnant women to have more severe symptoms (Pereira et al., 2019). Transmission via the uterus, vertical transmission, or nursing were all ruled out. Individuals who tested positive for COVID-19 had different guidelines for pregnancy, delivery, and nursing. An alarming increase in postpartum mental health conditions, including clinically relevant anxiety and depression, has been seen in recent years. The prevalence of domestic abuse seems to have grown. Prenatal care visits have decreased, the healthcare system has been overwhelmed, and potentially harmful policies have been implemented based on a lack of evidence. Women are significantly more likely than men to experience wage loss due to the pandemic, and working mothers are burdened with extra childcare responsibilities, as seen in the following ways.
- Transmission Inside the Uterus
During pregnancy, viral infections inside the uterus can result in pregnancy problems and fetal malformations in a woman. The placenta’s structure, which holds the fetus to the uterus, gives viruses the potential to transfer from the infected mother to the fetus.
The research on COVID-19 transfer from mother to baby is speculative, and further data is needed to establish suggested transmission methods. Research does not support intrauterine infections with COVID-19 caused by infected persons in pregnant women with medically or microbiologically identified viral infection cases during the third trimester. A few examples of neonatal infection may have been acquired in pregnancy. According to these findings, the probability of transfer from the mother to the kid is exceptionally minimal, potentially less than 1%. Nonetheless, it is commonly acknowledged that more extensive population-based long-term studies are necessary to establish the plausibility of inadvertent transmission.
According to a thorough study by Wu et al., 90.2 % who tested positive for COVID-19 had birth through C-section (Wu et al., 2020). Earlier numbers from Wuhan, China, showed that 93 percent of births were placed by cesarean section at the time. The reasons for this conduct are yet unclear; however, it may be connected to more active delivery room management during the start of the epidemic. According to a recent study, women giving birth at New York City hospitals between March 8 and April 2, 2020, did not have C-section rates that were statistically substantially higher than the national norm (Richardson et al., 2020).
- Obstetrics plus Delivery
Obstetrics deals with the care of women during pregnancy and childbirth and diagnosing and treating diseases affecting the female reproductive system. It also focuses on other women’s health issues, such as infertility, menopause, hormone difficulties, and contraception. In conjunction with the transmission of SARS-CoV-2 from mother to child during delivery, quantitative studies were utilized.
A few case studies, counting examining 108 deliveries in New York, indicate that vaginal delivery does not result in an elevated risk of disease for the neonate (Richardson et al, 2020). Despite early comforting data that vaginal birth does not raise the neonatal risk of infection, healthcare guidelines vary in their references for the mode of giving birth. According to research by Knight et al., 90.2 percent of women identified with COVID-19 delivered by C-section (Knight et al., 2020). Clinical recommendations advocate no visits or one healthy support person, while the American University of Obstetricians and the Association for Perinatal and Fetal Medicine also encourage hastened release.
- Breastfeeding and interaction with infants
Breastfeeding leads to more bonding interaction between mother and infant and promotes skin-to-skin contact, greater holding, and stroking. Breastfeeding helps to protect infants against short and long-term illnesses and diseases. Regarding the transmission of SARS-CoV-2 during breastfeeding, few studies were utilized.
The probability of new coronavirus transmission through breastfeeding is unknown. The bulk of milk samples from 37 women was harmful to SARS-CoV-2 (Smith et al., 2020). This shows that breast milk may protect from COVID-19 infection, while further data is required to confirm this. WHO and UNICEF suggested that nursing, sharing a room, skin interaction with the skin, and kangaroo concerns are maintained while adhering to infection control procedures (Smith et al., 2020). “Mothers with alleged or proven COVID-19 should be advised to commence or maintain breastfeeding,” the WHO states. Mothers should be counseled that the advantages of nursing far exceed any transmission concerns.” In comparison, the Centers for Disease Prevention and Control recommended that, although breastfeeding should be continued in general, “provisional separation of the infant from a woman who has established or probable the pandemic should be seriously considered to limit the risk of dissemination to the neonate.”
- Mental Well-Being
Mental illness is more prevalent in pregnant women and mothers’ moms than in non-pregnant adults. Numerous Corona virus-related research conducted in India, Italy, and China throughout the intrapartum and postnatal periods evaluated clinically significant anxiety as well as depression, as well as their symptoms, using self-reports and professional evaluations. Anxiety and sadness were connected with mothers worrying about vertical viral transmission to their newborns, local prenatal care services, and low social support (Smith et al., 2020). Additional parental mental health difficulties, including drug abuse and aggressive violence, have yet to be well investigated. COVID-19’s unpredictable nature and lack of social and familial support contributed to an increase in prenatal distress. Koenen and colleagues discovered that 40% of women tested positive for comment stress disorder during a worldwide study of pregnant and lactating females (PTSD) (Allotey et al., 2019). According to several writers, home births without qualified obstetric physicians funded to sadness and suffering among pregnant females and mothers in general.
- Care Throughout Pregnancy and the Postpartum Period
The COVID-19 outbreak necessitated the deferral of several non-“vital” health procedures to minimize transmission inside clinics, resulting in considerable decreases in prenatal and postnatal maintenance use.
In the United States, an online poll of 344 expectant mothers found that about one-third reported experiencing increased anxiety levels, with changes to prenatal checkups noted as a critical cause (Blitz et al., 2029). A modeling analysis of the pandemic’s indirect impacts in 118 LMIC predicted a drop in prenatal care of at least 18 percent, perhaps as much as 51.9 percent, and a similar reduction in the postpartum period.
National differences in perinatal care guidelines verified this approximation. According to a specialist obstetrician and gynecologist College, females in fetal development should visit once every eight weeks rather than four weeks. Prenatal care visits decreased from ten to sixteen to six (Richardson et al., 2020). Women often declined visits due to logistical concerns, familial pressure to split, and personal concerns about the virus. Maternal health providers observed decreased clinic attendance and an upsurge in women admitted to clinics too late for proper prenatal care. According to the Population Council, 9% of respondents in a survey of heads of families in five Nairobi slums forewent health care services such as maternity care and child immunization/nutrition programs. Treatment West Africa’s rapid gender analysis revealed a steady stream of false claims about the virus and general suspicion of health experts, prompting some men, especially in rural regions, to bar their wives from seeking health care. In Mali, most female participants said they could not get health care due to fear of the disease and confusion regarding the availability of services.
Knight et al. observed a significant decline in prenatal care services in a global cross-sectional study of maternity care providers. Throughout pregnancy, clinics reduced their operation hours, the number of approved visitors, and in-person visits (Knight et al., 2020). In certain locations in the U.K., women were given blood pressure monitors and urinalysis needles for prenatal examinations. Prenatal treatment was provided through telemedicine; however, accessibility varied by region. Respondents from the U.K. expressed interest in the effects of reduced rates on the durability of maternity care. At the same time, participants from LMICs accepted women’s denial of available communication systems, as telemedicine is far more difficult to obtain in rural areas, particularly among women.
- Healthcare Infrastructure
Outpatient clinics have been temporarily shuttered due to shelter-at-home orders, robbing many women of vital prenatal care and birth control access. By April, 5,633 static and portable hospitals and community health centers had been closed in 64 countries (Muralidar et al., 2020). According to the United Nations Development Program, if the COVID-19 disruption persists for six months, 48 million girls will be unable to access modern contraception (Knight et al., 2020). The United Kingdom’s medical system failed to recognize known public health dangers, increasing maternal mortality among expectant mothers infected with COVID-19. During the outbreak, it was anticipated that women and girls in the Comments section of Africa would experience major secondary effects, including a spike in maternal mortality.
A significant proportion of preterm births were iatrogenic, suggesting that healthcare professional conduct may cause. Changes in giving such behavior and care availability may result in better outcomes (lower preterm delivery) in certain circumstances but may also increase miscarriage.
- Inequity between Men and Women in the Working
Social exclusion and lockdown techniques used during the COVID-19 epidemic seriously affected economic sectors since interpersonal relationships were frequent and often unavoidable.
Women were highly represented in these sectors; the U.K. Labor Force Survey found that approximately 46% of working women and 39% of working men were employed in key sectors, respectively (Knight et al., 2020). During the pandemic, the average Canadian woman spent nearly 50 more hours per week on childcare than the average male. Women have destroyed 60% of all employment since the crisis started, according to Women Development figures. According to Labor Statistics, women accounted for 55% of America’s 20.5 million jobless employees in April 2020 alone.
- Domestic Abuse
Domestic abuse is one episode or sequence of controlling, coercive, threatening, demeaning, violent, or sexually violent behavior, typically committed by a partner or ex-partner and occasionally by a family member or caretaker. It occurs frequently, and most of the time, it affects women and is committed by men.
During the COVID-19 period, individuals were obliged to remain inside for prolonged periods due to lockdown measures, and early statistics indicated a significant impact on domestic violence. Police statistics were analyzed to see if there has been an increase in violence, and numerous nations have seen increases in domestic violence. Additionally, Domestic violence hotlines and charities in several nations have increased call volume since January 2020. Females’ rights New-fangled South Wales as well as the Foundation Lance d’Afrique. Burundi conducted non-representative surveys and discovered increased survivors’ requests to assist female frontline staff. Kenya’s Chief Justice reported that gender-based assault cases climbed by more than a third during the first two weeks of April alone (Pereira et al., 2019). Similarly, according to statistics from India’s Commission for Females, domestic abuse complaints more than quadrupled after Prime Minister Modi’s March 22020 lockdown announcement.
There is a shortage of meaningful epidemiologic studies on increasing Domestic violence, and the data that exist do not differentiate between pregnant women and moms. The range of reported instances is concerning, and the rise in DV is predicted to harm maternal health outcomes. The actual number of DV events is very certainly more than what is recorded, owing to lockdown precautions and concerns about virus propagation. There is a shortage of community-supporting women wishing to be free of abusers.
Discussion
Strengths and Limitation
This article provides a comprehensive assessment of the direct and indirect consequences of the COVID-19 outbreak on maternal health. Applying broad search terms and presence criteria, we were able to analyze information on the pandemic’s social and economic effects and long-term health consequences. However, since this study omitted literature in English and other languages, the results are likely biased toward countries where English is the primary language. However, it was not easy to locate published data on maternity care in LMICs. We compensate for this by including a variety of literary evaluations and news articles. Finally, although scoping reviews helped us to summarize the literature rapidly, they need more rigor of existing literature or meta-analysis.
While early research showed otherwise, new research employing large enough sample sizes and control groups revealed that expecting moms with COVID-19 signals are at a greater risk of bad outcomes than those who are negative. Additionally, this vulnerable demographic is already feeling the pandemic’s non-medical repercussions. While these interactions’ instant and middle consequences have become more apparent, the long-term consequences remain unknown and need more exploration.
Only now, inquests into the implications of the COVID-19 pandemic have lacked scientific method, which is reasonable considering time restraints and data availability; this uses research that rigorously tries to control for prior levels of critical results and demographic characteristics in examining time trends more credibly. While lowering prenatal visits in high-income countries does not always result in bad birth outcomes, limiting access to critical prenatal care in low- and lesser countries (LMIC) nearly invariably has a negative impact on the mother’s and infant’s health. Maintaining monitoring and reporting is crucial for determining if maternal morbidity and mortality rose throughout the outbreak and which communities were most afflicted.
The Covid-19 outbreak has raised many issues about the most effective methods for avoiding SARS-Cov-2 transmission while limiting unintended implications for family well-being and gender parity (Muralidar et al., 2020). Among them are the following: under what conditions and in what form should universities and daycares continue care? Which options for prenatal and postnatal care result in the best outcomes? Which economic support strategies advance gender equality and family well-being? While the disparate and inequitable application of healthcare policies within and across nations may not be optimal for outbreak response, it provides a reasonably close experiment for examining these concerns.
Simultaneously, regulations affecting pregnant and youthful women were made based on little evidence. Numerous such regulations can negatively impact pregnant women’s health and rights. Those who restrict aid and support throughout pregnancy and delivery require early baby separation, while those who require shorter postpartum durations cause the greatest difficulty. While the therapeutic explanation for the elevated C-section rates amongst pregnant women diagnosed with Covid-19 is unknown, these rates are troubling in light of the lack of evidence that C-section delivery reduces the likelihood of SARS-CoV-2 transmission or improves pregnancy outcomes.
Recommendation and Implications
These concerns have prompted us to make policy proposals that either has sufficient evidence to justify adoption or should be studied for moral and civil rights reasons. The first two are directly tied to health policy. Given the rarity of catastrophic outcomes associated with SARS-CoV-2 infection in neonates, we encourage the CDC to follow the WHO’s strong advice to keep the mother and baby dyad together when the woman has been proven to be infected with SARS-CoV-2 (Smith et al., 2020). While precautions are necessary, the advantages of early attachment and nursing exceed the infant’s risk of illness.
Second, medical institutions should consider the mental health consequences of any actions that limit transmission risk. There is compelling evidence that maternal mental illnesses have become more prevalent throughout the epidemic. Policies that restrict or prohibit giving birth in front of a customer service agent or are likely to trigger discomfort or worsen pre-existing mental health problems should be avoided. With many medical facilities attempting to minimize postpartum hospitalizations or providing postpartum consulting through remote patient monitoring, there is a danger that is screening for postmortem.
With many medical facilities attempting to minimize postpartum hospitalizations or providing postpartum consulting through remote patient monitoring, there is a danger that screening for post-Healthcare providers must be cognizant of the additional psychological demands imposed on pregnant or parenting patients.
Finally, closures of daycares and schools have a terrible impact on caregivers, particularly women, who often shoulder the bulk of childcare responsibilities. Along with other disease outbreak employment repercussions, these closures jeopardize the workforce’s gender balance. Without significant policy mitigation, this danger may have far-reaching implications. We strongly encourage authorities to prioritize reconstructing safe schools and childcare facilities before enforcing shelter-in-place restrictions or conducting other communicable disease activities. Inability to do so will almost certainly result in female employment losses in the near term, given women’s increasing childcare responsibilities, and put poor single moms and low-income households in danger of food insecurity.
Conclusion
While comprehensive education has not yet been completed, early evidence from this preliminary assessment shows that most evaluations of the COVID-19 scenario are projected to have a disproportionate impact on women. The danger of transmission from mother to child during pregnancy or breastfeeding is well understood. Pregnancy appears to be a coronavirus-susceptible time, but this needs to be proven further by the well and conducted research. A higher risk of discomfort and psychological issues during and after pregnancy is predicted during a pandemic, although elevated data are also absent in this context. Similarly, an increase in domestic abuse is anticipated and supported by various research; nevertheless, more comprehensive data are necessary. Similarly, maternal morbidity and mortality research is scarce. Thorough epidemiological research must be conducted to identify the health consequences of SARS-CoV-2 infection and the influence of health care and accessibility on maternal health. However, our data indicate that moms with children are more likely than males and females without children to encounter employment and income restrictions during a pandemic. Moms, particularly single mothers, are susceptible to food insecurity. Women face comparable socioeconomic effects in a broad array of high- and reduced nations.
References
Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C, O’Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ. Characteristics and Outcomes of Pregnant Women Admitted to Hospital with Confirmed SARS-CoV-2 Infection in the U.K.: National Population-Based Cohort Study. BMJ. 2020;369:2107. https://doi.org/10.1136/bmj.m2107.
Muralidar S, Ambi SV, Sekaran S, Krishnan UM. The emergence of COVID-19 as a global pandemic: Understanding the epidemiology, immune response and potential therapeutic targets of SARS-CoV-2. Biochimie. 2020;179:85–100. https://doi.org/10.1016/j.biochi.2020.09.018
Wu C, Yang W, Wu X, Zhang T, Zhao Y, Ren W, Xia J. Clinical manifestation and laboratory characteristics of SARS-CoV-2 infection in pregnant women. Virologica Sinica. 2020;35(3):305–10. https://doi.org/10.1007/s12250-020-00227-0.
Xu L, Yang Q, Shi H, Lei S, Liu X, Zhu Y, Wu Q, Ding X, Tian Y, Hu Q, Chen F, et al. Clinical presentations and outcomes of SARS-CoV-2 infected pneumonia in pregnant women and health status of their neonates. Sci Bull. 2020. https://doi.org/10.1016/j.scib.2020.04.040.
Smith V, Seo D, Warty R, Payne O, Salih M, Chin KL, Ofori-Asenso R, et al. Maternal and Neonatal Outcomes Associated with COVID-19 Infection: a Systematic Review. 2020;5(6):e0234187. https://doi.org/10.1371/journal.pone.0234187.
Allotey J, Stallings E, Bonet M, Yap M, Chatterjee S, Kew T, Debenham L, Llavall AC, Dixit A, Zhou D, Balaji R, Lee SI, Qiu X, Yuan M, Coomar D, van Wely M, van Leeuwen E, Kostova E, Kunst H. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ. 2020. https://doi.org/10.1136/bmj.m3320.
Pereira A, Cruz-Melguizo S, Adrien M, Fuentes L, Marin E, Perez-Medina T. Clinical Course of Coronavirus Disease-2019 in Pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 2020;99(7):839–47. https://doi.org/10.1111/aogs.13921.
Blitz MJ, Rochelson B, Meirowitz N, Prasannan L, Rafael TJ, et al. Maternal mortality among women with coronavirus disease 2019. Am J Obstet Gynecol. 2019. https://doi.org/10.1016/j.ajog.2020.06.020.
Jafari, M., Pormohammad, A., Sheikh Neshin, S. A., Ghorbani, S., Bose, D., Alimohammadi, S.,
Basirjafari, S., Mohammadi, M., Rasmussen-Ivey, C., Razizadeh, M. H., Nouri-Vaskeh, M., & Zarei, M. (2021). Clinical characteristics and outcomes of pregnant women with COVID-19 and comparison with control patients: A systematic review and meta-analysis. Reviews in medical virology, 31(5), 1–16. https://doi.org/10.1002/rmv.2208
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