Collateral damage of the Covid-19 pandemic: a Dutch perinatal perspective
Dear Editor,
In the current Covid-19 pandemic, it is paramount to fairly balance the health and interests of Covid-19 patients and non-Covid-19 patients (1). Already, there are disquieting signs that show how the necessary measures taken to address Covid-19 put a strain on the delivery of adequate perinatal care.
Data on the course of Covid-19 in pregnant women, fetus and neonate is limited. Contrary to the previous corona epidemics, such as SARS-CoV and MERS-Cov, where approximately 20% of the infected pregnant women died (2,3), so far women in the third trimester of pregnancy with Covid-19 pneumonia show similar clinical characteristics as non-pregnant women and adverse neonatal outcomes in Covid-19 infected mothers have been limited. The RCOG has rapidly initiated guidelines, like other professional organisations based on the (limited) available data (4). Nevertheless, the Covid-19 pandemic will have multifaceted effects on the quality and clinical outcomes of perinatal care.
We are observing an increased hesitation on the part of pregnant women and their partners to visit the hospital as they perceive an increased risk of infection. For this reason, they are more likely to cancel their standard antenatal outpatient clinic appointments. Depending on the gestational age, medical and/or social status this may prove to be detrimental to both maternal and fetal health; maternal hypertension will not be detected timely and treated and there is an increased likelihood of inadequate assessment of fetal well-being. One such key evaluation of the fetus, is the fetal anomaly scan around 20 weeks of pregnancy. In the Netherlands these scans are now progressively being cancelled or postponed. As these scans are important to identify and manage fetal anomalies, this is cause for concern. Moreover, these scans are paramount for the reproductive autonomy of pregnant women. The informed choice of pregnant women, whether to continue or terminate pregnancy, which in the Netherlands is open up to 24 weeks amenorrhea, depends heavily on the timely opportunity to have and interpret a fetal anomaly scan. It is unknown whether future parents are aware of these adverse consequences when they cancel their appointment.
Healthcare professionals themselves are also emotionally affected by the sudden rapid global and national expansion of positive Covid-19 cases (including fatal cases under professionals) and the sudden initiation of daily changing national and local isolation protocols. Their unfamiliarity with such a crisis and the fear of getting infected themselves may affect their persuasiveness to aid patients to adhere to their appointments.
Despite the birth of one’s child is perceived as one of the most important life events, currently measurements are put in place in hospitals, not only in the Netherlands, to forbid the entrance of partners, with and without complaints to be present during labour and elective caesarean section.
This results in a situation in which the pregnant woman will be alone and isolated during and after the birth of their child. After discharge the new family is isolated from family and friends due to social distancing. Attention is needed, especially for vulnerable women like those socially and psychologically challenged, in the puerperal period because of a possibly higher risk of postpartum depression.
Fear of getting infected, and hospitals only allowing none or only one person to support during labour seem to result already in more home births (5,6). The Netherlands has a well-established national system for home births for low risk pregnancies in case the domestic environment is safe and a hospital is in close proximity. Loosening these safety criteria in combination with the reduced immediate ambulance availability, this pandemic crisis might also result in increased maternal and fetal morbidity and mortality.
After birth in many hospitals only one visitor is allowed to the neonatal intensive care unit (NICU) per patient per day. This means that the parents cannot be together with their child which might result in long-term bonding problems as well as parental psychosocial complications and depression.
Altogether we are very worried about the collateral damage to pregnant women, partner and their babies caused by the Covid-19 pandemic, not only in The Netherlands.
Attention to and registration of the less obvious consequences should be initiated timely for further understanding of these adverse sequalae and to be able to put secondary prevention programs in place.
References
1. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020.
2. Wong SF, Chow KM, de Swiet M. Severe acute respiratory syndrome and pregnancy. BJOG 2003;110:641-2.
3. Assiri A, Abedi GR, Al Masri M, Bin Saeed A, Gerber SI, Watson JT. Middle East 601 respiratory syndrome coronavirus infection during pregnancy: a report of 5 cases from 602 Saudi Arabia. Clin Infect Dis 2016;63:9513.
4. COVID 19 and pregnancy.BMJ 2020; 369:m1672
5. ‘Giving birth in times of coronavirus: COVID-19 leads couples to consider home births’. By Jack Parrock. Euronews. 28-4-2020
6. ‘Should You Have a Home Birth Because of Coronavirus?’ By Katharine Gammon. New York Times, 30 March 2020
Competing interests:
No competing interests
12 May 2020
E.J. (Joanne) Verweij
Obstetrician
H. Ismaili M’hamdi, Ph.D., E.A.P. Steegers, M.D. Ph.D., I.K.M. Reiss, M.D. Ph.D., S. Schoenmakers, M.D. Ph.D.
Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam.
Rapid Response:
Collateral damage of the Covid-19 pandemic: a Dutch perinatal perspective
Dear Editor,
In the current Covid-19 pandemic, it is paramount to fairly balance the health and interests of Covid-19 patients and non-Covid-19 patients (1). Already, there are disquieting signs that show how the necessary measures taken to address Covid-19 put a strain on the delivery of adequate perinatal care.
Data on the course of Covid-19 in pregnant women, fetus and neonate is limited. Contrary to the previous corona epidemics, such as SARS-CoV and MERS-Cov, where approximately 20% of the infected pregnant women died (2,3), so far women in the third trimester of pregnancy with Covid-19 pneumonia show similar clinical characteristics as non-pregnant women and adverse neonatal outcomes in Covid-19 infected mothers have been limited. The RCOG has rapidly initiated guidelines, like other professional organisations based on the (limited) available data (4). Nevertheless, the Covid-19 pandemic will have multifaceted effects on the quality and clinical outcomes of perinatal care.
We are observing an increased hesitation on the part of pregnant women and their partners to visit the hospital as they perceive an increased risk of infection. For this reason, they are more likely to cancel their standard antenatal outpatient clinic appointments. Depending on the gestational age, medical and/or social status this may prove to be detrimental to both maternal and fetal health; maternal hypertension will not be detected timely and treated and there is an increased likelihood of inadequate assessment of fetal well-being. One such key evaluation of the fetus, is the fetal anomaly scan around 20 weeks of pregnancy. In the Netherlands these scans are now progressively being cancelled or postponed. As these scans are important to identify and manage fetal anomalies, this is cause for concern. Moreover, these scans are paramount for the reproductive autonomy of pregnant women. The informed choice of pregnant women, whether to continue or terminate pregnancy, which in the Netherlands is open up to 24 weeks amenorrhea, depends heavily on the timely opportunity to have and interpret a fetal anomaly scan. It is unknown whether future parents are aware of these adverse consequences when they cancel their appointment.
Healthcare professionals themselves are also emotionally affected by the sudden rapid global and national expansion of positive Covid-19 cases (including fatal cases under professionals) and the sudden initiation of daily changing national and local isolation protocols. Their unfamiliarity with such a crisis and the fear of getting infected themselves may affect their persuasiveness to aid patients to adhere to their appointments.
Despite the birth of one’s child is perceived as one of the most important life events, currently measurements are put in place in hospitals, not only in the Netherlands, to forbid the entrance of partners, with and without complaints to be present during labour and elective caesarean section.
This results in a situation in which the pregnant woman will be alone and isolated during and after the birth of their child. After discharge the new family is isolated from family and friends due to social distancing. Attention is needed, especially for vulnerable women like those socially and psychologically challenged, in the puerperal period because of a possibly higher risk of postpartum depression.
Fear of getting infected, and hospitals only allowing none or only one person to support during labour seem to result already in more home births (5,6). The Netherlands has a well-established national system for home births for low risk pregnancies in case the domestic environment is safe and a hospital is in close proximity. Loosening these safety criteria in combination with the reduced immediate ambulance availability, this pandemic crisis might also result in increased maternal and fetal morbidity and mortality.
After birth in many hospitals only one visitor is allowed to the neonatal intensive care unit (NICU) per patient per day. This means that the parents cannot be together with their child which might result in long-term bonding problems as well as parental psychosocial complications and depression.
Altogether we are very worried about the collateral damage to pregnant women, partner and their babies caused by the Covid-19 pandemic, not only in The Netherlands.
Attention to and registration of the less obvious consequences should be initiated timely for further understanding of these adverse sequalae and to be able to put secondary prevention programs in place.
References
1. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020.
2. Wong SF, Chow KM, de Swiet M. Severe acute respiratory syndrome and pregnancy. BJOG 2003;110:641-2.
3. Assiri A, Abedi GR, Al Masri M, Bin Saeed A, Gerber SI, Watson JT. Middle East 601 respiratory syndrome coronavirus infection during pregnancy: a report of 5 cases from 602 Saudi Arabia. Clin Infect Dis 2016;63:9513.
4. COVID 19 and pregnancy.BMJ 2020; 369:m1672
5. ‘Giving birth in times of coronavirus: COVID-19 leads couples to consider home births’. By Jack Parrock. Euronews. 28-4-2020
6. ‘Should You Have a Home Birth Because of Coronavirus?’ By Katharine Gammon. New York Times, 30 March 2020
Competing interests: No competing interests