Re: Risks to children and young people during covid-19 pandemic: The Reverse Titanic phenomenon: “Women and children last” – the implications of the COVID-19 pandemic and health system shock on reproductive, perinatal, and paediatric health
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Risks to children and young people during covid-19 pandemic
Re: Risks to children and young people during covid-19 pandemic: The Reverse Titanic phenomenon: “Women and children last” – the implications of the COVID-19 pandemic and health system shock on reproductive, perinatal, and paediatric health
Dear Editor
The COVID-19 pandemic has led to abrupt changes in health service delivery, from face-to-face to largely virtual interactions, to protect those vulnerable to the virus (beneficial) and reacting to staff shortages (potentially harmful). This dislocation of care is exacerbated by social distancing requirements. For the elderly and adults with significant co-morbidities, this is clearly evidence-based, but may result in deleterious delays in care seeking by those with acute health events (e.g., myocardial infarction and stroke). For young women and children who usually experience mild symptoms of COVID-19, these changes in service delivery may have gone too far, jeopardising non-COVID-19 related health.
When the Titanic suffered an abrupt and catastrophic maritime shock, the safety and survival of women and children were prioritised, however this health system shock may have resulted in an inadvertent reverse Titanic phenomenon. There has been increasing concern about the impact on pregnant women and children, as voiced by the UK Secretary of State for Health and professional groups such as the Royal Colleges of Midwifery (RCM), Obstetrics and Gynaecology (RCOG), Paediatrics and Child Health (RCPCH), and General practice (RCGP) [1].
To reduce infection risks to pregnant women and respond to staff shortages, the RCOG’s regularly updated national guidance has advised reconfiguration of antenatal services towards virtual appointments for women with both low- and high-risk pregnancies, and reduced ultrasound services and community visits [2]. The UK Government has cautioned that pregnant women may be at higher risk of severe COVID-19-related illness and should be especially compliant with social distancing [3]. Similar guidance from the RCPCH covers: COVID-19 preparations, occupational health, 'shielding' advice for vulnerable children and young people, safeguarding and child protection, and services normally delivered in acute/emergency, neonatal and community settings [4].
What are the measured and potential implications of these changes in behaviour?
Previous Coronavirus epidemics (e.g., SARS, MERS) were probably associated with additional maternal and perinatal risks [5]. A meta-analysis of maternal and perinatal adverse outcomes related to COVID-19 has observed that while the risk of preterm birth and Caesarean delivery are increased, maternal and serious neonatal morbidity appear to be unaltered [6]; however, most of this evidence comes from China and the USA, with higher levels of intervention, especially Caesarean delivery, than the UK. Current screening measures are missing close to 90% of COVID-19 positive pregnant women, as this proportion are asymptomatic [7].
In the political sphere outside the UK, some politicians, known to be inclined to limit women’s reproductive choices, have used the pandemic as an excuse to reduce access to abortion services [8].
Social distancing is having both direct and indirect impacts on antenatal and paediatric care. As many as 50% of pregnant women will have a condition or complication that necessitates additional appointments or multidisciplinary care during pregnancy. Similarly, children with long-term and complex medical conditions need multidisciplinary care, and when acute exacerbations occur often require face-to-face consultations. Antenatal appointments that do not require measurement of fundal height, blood or urine tests, or scans; and non-urgent paediatric appointments can and should be provided virtually.
The World Health Organization recommendations for antenatal care state that the major auditable standard for a prenatal visit is the measurement of blood pressure [9]. Despite a significant NHS investment in home blood pressure monitoring targeting pregnant women with known hypertension, the rapid shift to virtual care reduces face-to-face visits by two per pregnancy. Therefore, blood pressure measurement is missing from the care of most previously normotensive women. Most pregnancy hypertension arises at term, and without detection and appropriate clinical response, including normalising blood pressure [10], increases the risks associated with severe pregnancy hypertension [11]. Individual units should identify clinicians capable of assessing and triaging risks of fetal growth disorders to assist with triaging of referrals; whether in person or remote. As individual units’ demands in each of the categories (moderate and high) will vary, units may need to make local decisions about risk factor prioritisation within and across categories.
For paediatrics, a system of triaging and providing virtual clinics is needed; integrated care can provide improved outcomes [12], and system transformations are underway in several areas [13].
Clinicians are reporting widespread and shared observation of reductions in hospital attendances by pregnant women to early pregnancy, day assessment, and triage units, with associated reductions in referrals for both maternal and fetal indications. This is likely to result in unintended negative effects of COVID-19 related to delayed presentation and resulting complications from early (e.g., ectopic pregnancy) to late (e.g., stillbirth) pregnancy.
Similarly, in child health, there are documented sharp declines in emergency department attendances for children with acute illnesses including potentially life-threatening conditions such as asthma and acute respiratory infections [14], and a growing concern by RCPCH and RCGP about reported falling vaccination rates and the potential for resurgent vaccine-preventable infections such as measles [15]. We need to monitor the maternal, perinatal and child health consequences of the COVID-19 pandemic; the challenge will be discriminating between the direct (e.g., COVID-19 infection) and indirect (e.g., altered care seeking) causes.
Services should offer a combination of face-to-face and remote care, according to the woman’s and baby’s/child’s needs, while prioritising face-to-face visits for women and children with: (i) known psycho-social vulnerabilities; (ii) operative birth; (iii) prematurity/low birthweight; or (iv) other medical, neonatal, and childhood chronic conditions and complexities.
There is likely to be a COVID-19 legacy through changes in maternity and child health, and through the health system response to the shock caused by the pandemic. While the Titanic disaster resulted in significant improvements in maritime design, the COVID-19 pandemic has the potential to catalyse important, beneficial, and cost-effective health system improvements in the medium and long term. This acute phase of risks to reproductive, perinatal and child health must be acknowledged and measured. Health system responses must be monitored, and lessons learnt from innovations and challenges - both to improve future pandemic planning and health system performance during more stable times.
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.
References
1. Roxby P. Coronavirus: plea for public to get medical care when they need it London: BBC; 2020 [updated 27 April 2020. Available from: https://www.bbc.co.uk/news/health-52417599 accessed 27 April 2020.
2. RCOG. Guidance for maternal medicine services in the evolving coronavirus (COVID-19) pandemic: information for health professionals. London: Royal College of Obstetricians and Gynaecologists, 2020.
3. HMG. Guidance: COVID-19: guidance on social distancing and for vulnerable people Guidance on social distancing for everyone in the UK, including children, and protecting older people and vulnerable people. London: Her Majesty's Government; 2020 [updated 30 March 2020. Available from: https://www.gov.uk/government/publications/covid-19-guidance-on-social-d... accessed 26 April 2020.
4. RCPCH. Key topics: COVID-19 London: Royal College of Paediatrics and Child Health; 2020 [Available from: https://www.rcpch.ac.uk/key-topics/covid-19 accessed 26 April 2020.
5. Di Mascio D, Khalil A, Saccone G, et al. Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020:100107. doi: 10.1016/j.ajogmf.2020.100107 [published Online First: 2020/04/16]
6. Khalil A, Kalafat E, O’Brien P, et al. SARS-CoV-2 infection in pregnancy: a systematic review and meta-analysis of clinical features and pregnancy outcomes. Lancet Infect Dis 2020;[submitted]
7. Sutton D, Fuchs K, D'Alton M, et al. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med 2020 doi: 10.1056/NEJMc2009316 [published Online First: 2020/04/14]
8. Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 pandemic - ensuring access to an essential health service. N Engl J Med 2020 doi: 10.1056/NEJMp2008006 [published Online First: 2020/04/10]
9. WHO. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization, 2016.
10. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med 2015;372(5):407-17. doi: 10.1056/NEJMoa1404595 [published Online First: 2015/01/30]
11. Magee LA, von Dadelszen P, Singer J, et al. The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study): is severe hypertension just an elevated blood pressure? Hypertension 2016;68(5):1153-59. doi: 10.1161/HYPERTENSIONAHA.116.07862 [published Online First: 2016/09/14]
12. Wolfe I, Satherley RM, Scotney E, et al. Integrated care models and child health: a meta-analysis. Pediatrics 2020;145(1) doi: 10.1542/peds.2018-3747 [published Online First: 2020/01/01]
13. Newham JJ, Forman J, Heys M, et al. Children and Young People's Health Partnership (CYPHP) Evelina London model of care: protocol for an opportunistic cluster randomised controlled trial (cRCT) to assess child health outcomes, healthcare quality and health service use. BMJ Open 2019;9(8):e027301. doi: 10.1136/bmjopen-2018-027301 [published Online First: 2019/09/05]
14. PHE. Emergency Department Syndromic Surveillance System: England Birmingham: Public Health England Real-time Syndromic Surveillance Team; 2020 [updated 22 April 2020. Week 16:[Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploa... accessed 27 April 2020.
15. Sample I. Missed vaccinations could lead to other fatal outbreaks, doctors warn. The Guardian 2020 26 April 2020.
Competing interests:
No competing interests
30 April 2020
Peter von Dadelszen
professor of global women's health & honorary consultant obstetrician
Asma Khalil, professor, consultant; Ingrid Wolfe, clinical senior lecturer, consultant; Nikos A Kametas, clinical reader, consultant; Patrick O’Brien, honorary senior lecturer, consultant; Laura A Magee, professor, consultant
Rapid Response:
Re: Risks to children and young people during covid-19 pandemic: The Reverse Titanic phenomenon: “Women and children last” – the implications of the COVID-19 pandemic and health system shock on reproductive, perinatal, and paediatric health
Dear Editor
The COVID-19 pandemic has led to abrupt changes in health service delivery, from face-to-face to largely virtual interactions, to protect those vulnerable to the virus (beneficial) and reacting to staff shortages (potentially harmful). This dislocation of care is exacerbated by social distancing requirements. For the elderly and adults with significant co-morbidities, this is clearly evidence-based, but may result in deleterious delays in care seeking by those with acute health events (e.g., myocardial infarction and stroke). For young women and children who usually experience mild symptoms of COVID-19, these changes in service delivery may have gone too far, jeopardising non-COVID-19 related health.
When the Titanic suffered an abrupt and catastrophic maritime shock, the safety and survival of women and children were prioritised, however this health system shock may have resulted in an inadvertent reverse Titanic phenomenon. There has been increasing concern about the impact on pregnant women and children, as voiced by the UK Secretary of State for Health and professional groups such as the Royal Colleges of Midwifery (RCM), Obstetrics and Gynaecology (RCOG), Paediatrics and Child Health (RCPCH), and General practice (RCGP) [1].
To reduce infection risks to pregnant women and respond to staff shortages, the RCOG’s regularly updated national guidance has advised reconfiguration of antenatal services towards virtual appointments for women with both low- and high-risk pregnancies, and reduced ultrasound services and community visits [2]. The UK Government has cautioned that pregnant women may be at higher risk of severe COVID-19-related illness and should be especially compliant with social distancing [3]. Similar guidance from the RCPCH covers: COVID-19 preparations, occupational health, 'shielding' advice for vulnerable children and young people, safeguarding and child protection, and services normally delivered in acute/emergency, neonatal and community settings [4].
What are the measured and potential implications of these changes in behaviour?
Previous Coronavirus epidemics (e.g., SARS, MERS) were probably associated with additional maternal and perinatal risks [5]. A meta-analysis of maternal and perinatal adverse outcomes related to COVID-19 has observed that while the risk of preterm birth and Caesarean delivery are increased, maternal and serious neonatal morbidity appear to be unaltered [6]; however, most of this evidence comes from China and the USA, with higher levels of intervention, especially Caesarean delivery, than the UK. Current screening measures are missing close to 90% of COVID-19 positive pregnant women, as this proportion are asymptomatic [7].
In the political sphere outside the UK, some politicians, known to be inclined to limit women’s reproductive choices, have used the pandemic as an excuse to reduce access to abortion services [8].
Social distancing is having both direct and indirect impacts on antenatal and paediatric care. As many as 50% of pregnant women will have a condition or complication that necessitates additional appointments or multidisciplinary care during pregnancy. Similarly, children with long-term and complex medical conditions need multidisciplinary care, and when acute exacerbations occur often require face-to-face consultations. Antenatal appointments that do not require measurement of fundal height, blood or urine tests, or scans; and non-urgent paediatric appointments can and should be provided virtually.
The World Health Organization recommendations for antenatal care state that the major auditable standard for a prenatal visit is the measurement of blood pressure [9]. Despite a significant NHS investment in home blood pressure monitoring targeting pregnant women with known hypertension, the rapid shift to virtual care reduces face-to-face visits by two per pregnancy. Therefore, blood pressure measurement is missing from the care of most previously normotensive women. Most pregnancy hypertension arises at term, and without detection and appropriate clinical response, including normalising blood pressure [10], increases the risks associated with severe pregnancy hypertension [11]. Individual units should identify clinicians capable of assessing and triaging risks of fetal growth disorders to assist with triaging of referrals; whether in person or remote. As individual units’ demands in each of the categories (moderate and high) will vary, units may need to make local decisions about risk factor prioritisation within and across categories.
For paediatrics, a system of triaging and providing virtual clinics is needed; integrated care can provide improved outcomes [12], and system transformations are underway in several areas [13].
Clinicians are reporting widespread and shared observation of reductions in hospital attendances by pregnant women to early pregnancy, day assessment, and triage units, with associated reductions in referrals for both maternal and fetal indications. This is likely to result in unintended negative effects of COVID-19 related to delayed presentation and resulting complications from early (e.g., ectopic pregnancy) to late (e.g., stillbirth) pregnancy.
Similarly, in child health, there are documented sharp declines in emergency department attendances for children with acute illnesses including potentially life-threatening conditions such as asthma and acute respiratory infections [14], and a growing concern by RCPCH and RCGP about reported falling vaccination rates and the potential for resurgent vaccine-preventable infections such as measles [15]. We need to monitor the maternal, perinatal and child health consequences of the COVID-19 pandemic; the challenge will be discriminating between the direct (e.g., COVID-19 infection) and indirect (e.g., altered care seeking) causes.
Services should offer a combination of face-to-face and remote care, according to the woman’s and baby’s/child’s needs, while prioritising face-to-face visits for women and children with: (i) known psycho-social vulnerabilities; (ii) operative birth; (iii) prematurity/low birthweight; or (iv) other medical, neonatal, and childhood chronic conditions and complexities.
There is likely to be a COVID-19 legacy through changes in maternity and child health, and through the health system response to the shock caused by the pandemic. While the Titanic disaster resulted in significant improvements in maritime design, the COVID-19 pandemic has the potential to catalyse important, beneficial, and cost-effective health system improvements in the medium and long term. This acute phase of risks to reproductive, perinatal and child health must be acknowledged and measured. Health system responses must be monitored, and lessons learnt from innovations and challenges - both to improve future pandemic planning and health system performance during more stable times.
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.
References
1. Roxby P. Coronavirus: plea for public to get medical care when they need it London: BBC; 2020 [updated 27 April 2020. Available from: https://www.bbc.co.uk/news/health-52417599 accessed 27 April 2020.
2. RCOG. Guidance for maternal medicine services in the evolving coronavirus (COVID-19) pandemic: information for health professionals. London: Royal College of Obstetricians and Gynaecologists, 2020.
3. HMG. Guidance: COVID-19: guidance on social distancing and for vulnerable people Guidance on social distancing for everyone in the UK, including children, and protecting older people and vulnerable people. London: Her Majesty's Government; 2020 [updated 30 March 2020. Available from: https://www.gov.uk/government/publications/covid-19-guidance-on-social-d... accessed 26 April 2020.
4. RCPCH. Key topics: COVID-19 London: Royal College of Paediatrics and Child Health; 2020 [Available from: https://www.rcpch.ac.uk/key-topics/covid-19 accessed 26 April 2020.
5. Di Mascio D, Khalil A, Saccone G, et al. Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020:100107. doi: 10.1016/j.ajogmf.2020.100107 [published Online First: 2020/04/16]
6. Khalil A, Kalafat E, O’Brien P, et al. SARS-CoV-2 infection in pregnancy: a systematic review and meta-analysis of clinical features and pregnancy outcomes. Lancet Infect Dis 2020;[submitted]
7. Sutton D, Fuchs K, D'Alton M, et al. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med 2020 doi: 10.1056/NEJMc2009316 [published Online First: 2020/04/14]
8. Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 pandemic - ensuring access to an essential health service. N Engl J Med 2020 doi: 10.1056/NEJMp2008006 [published Online First: 2020/04/10]
9. WHO. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization, 2016.
10. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med 2015;372(5):407-17. doi: 10.1056/NEJMoa1404595 [published Online First: 2015/01/30]
11. Magee LA, von Dadelszen P, Singer J, et al. The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study): is severe hypertension just an elevated blood pressure? Hypertension 2016;68(5):1153-59. doi: 10.1161/HYPERTENSIONAHA.116.07862 [published Online First: 2016/09/14]
12. Wolfe I, Satherley RM, Scotney E, et al. Integrated care models and child health: a meta-analysis. Pediatrics 2020;145(1) doi: 10.1542/peds.2018-3747 [published Online First: 2020/01/01]
13. Newham JJ, Forman J, Heys M, et al. Children and Young People's Health Partnership (CYPHP) Evelina London model of care: protocol for an opportunistic cluster randomised controlled trial (cRCT) to assess child health outcomes, healthcare quality and health service use. BMJ Open 2019;9(8):e027301. doi: 10.1136/bmjopen-2018-027301 [published Online First: 2019/09/05]
14. PHE. Emergency Department Syndromic Surveillance System: England Birmingham: Public Health England Real-time Syndromic Surveillance Team; 2020 [updated 22 April 2020. Week 16:[Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploa... accessed 27 April 2020.
15. Sample I. Missed vaccinations could lead to other fatal outbreaks, doctors warn. The Guardian 2020 26 April 2020.
Competing interests: No competing interests