This post is the first of a two-part series exploring the potential and realized impact of the COVID-19 on maternal health. While this post focuses on the United States, currently the country reporting the highest number of cases, the next in the series will focus on low and middle- income countries across the world.
As the COVID-19 pandemic changes much of life as we know it, scientists and health professionals are racing to understand the clinical, public health, and social impacts of the pandemic in the short and long-term. In the United States the field of maternal health, long underfunded and understudied, recently has come to the forefront of public health debates with the reassertion of gross racial inequities in maternal mortality. While pregnant and postpartum people do not seem to be at a particularly high risk of COVID-19 complications, the social and economic impacts of COVID-19 will negatively affect pregnant and parenting people, in ways that may set back maternal healthcare and the well-being of families for years to come.
The data show that COVID-19 is most dangerous for elderly persons and for people with underlying health conditions, especially heart disease, hypertension, and obesity. Case reports have suggested that pregnant people are not at a higher risk of developing COVID-19 complications and that transmission to the fetus during pregnancy is unlikely. However, the Centers for Disease Control and Prevention (CDC) continues to urge precaution as pregnant people are often more susceptible to infection. Clinically, this is good news for maternal health, but this early data should be interpreted with caution. More research is needed to understand the particular impact of COVID-19 infection during pregnancy and the postpartum period, as well as the long-term outcomes of children exposed to COVID-19.
It is likely that the real impact of COVID-19 on maternal health will be felt in two areas:
- constrained access to reproductive and maternal healthcare and a subsequent increase in adverse health outcomes; and
- rapid societal changes disproportionately and negatively affecting families, especially those from marginalized communities.
The first will be most drastically felt in the short-term, with possible repercussions that continue for years. As COVID-19 sweeps through the United States and overwhelms local hospitals (a phenomenon we are already seeing in New York City), maternal health will suffer as resources are diverted to combating the virus. The difficulty of tracking higher-risk pregnancies will intensify as prenatal checkups become virtual, and the fear of contracting the virus deters women from seeking in-clinic checkups and even hospital deliveries. Some hospitals have already moved to limit or eliminate companions during labor (hospitals in New York have since rolled this policy back) removing access to the proven health benefits of continuous support from a family member or lay professional. As the next few years pass, funds may continue to be redirected to acute care, infectious disease, and vaccine efforts, potentially continuing struggles to fund maternity care, especially outside of major cities.
At the same time, temporary restrictions on reproductive healthcare access, particularly abortion, are being put into place in several states. For example, officials in Ohio, Mississippi, Texas, Alabama, Iowa, and Oklahoma have labeled abortions as “elective” procedures. Texas’ governor, Greg Abbott recently issued an executive order stopping all elective procedures, including abortion, until April 21st, a measure likely to be extended given the continuing rise in COVID-19 cases. Women in states with these restrictions who seek an abortion will be forced to either 1) travel across state lines, endangering themselves and others to receive care, or 2) wait until the temporary ban is over, by which point they may have exceeded gestational age limits. Even in states that have not enacted temporary bans on abortion, paying for the procedure which is not covered by federal Medicaid funds or many private insurance providers, will be prohibitively difficult in a climate with soaring unemployment. Research has shown that those turned away for wanted abortions are more likely to suffer from maternal morbidity and mortality.
So, will these threats to maternal health lead to a subsequent spike in maternal mortality and morbidity? Only time and data will tell. One study estimated that during the Ebola epidemic, Sierra Leone saw a stark decrease in women who accessed medical treatment during their pregnancy and a 34% increase in maternal mortality for those who gave birth in a facility. While it is certainly true that the U.S. healthcare system is better resourced, the impact of the Coronavirus pandemic on maternal health may still be substantial, especially for the most vulnerable. The United States has the highest income inequality among the G7 nations, and a comparatively weak social safety net, and those who are unhoused, incarcerated, undocumented, or otherwise marginalized are likely to suffer the brunt of adverse maternal health outcomes.
The short-term sociological consequences are already being felt by a shockingly large number of Americans. Jobless claims exceed 20 million in four weeks, inflicting a toll on the labor force not seen since the Great Depression. Yet, the job losses and layoffs in the United States have, to this point, predominately affected women, young people, and those with only a high school education. With income loss and panic-buying exacerbating food supply chain issues and creating localized shortages, food insecurity increasingly will be an issue, especially for low-income families. Formula-fed infants are particularly affected by this, as parents are struggling to find and afford formula as well as diapers and wipes, especially those utilizing WIC.
Reports of domestic and sexual violence to hotlines, shelters, and police increase during or following disasters, and the added stress and stay at home orders in effect throughout the country have indeed led to increased reporting of domestic abuse. At the same time, the pandemic makes it more difficult, costly, and confusing to access shelter and other services. Pregnancy is a risk factor for intimate partner violence, and the health consequences of abuse during pregnancy can be severe. During the current period of lock down and social distancing, more women will experience physical or sexual violence at the hands of an intimate partner and that the violence will be more extreme.
While these short-term crises are likely to stabilize in the coming months, the consequences of financial insecurity will likely be seen for a much longer period. Many of the jobs lost during the COVID-19 crisis are unlikely to return. Since lay-offs and furloughs largely affect women, we could see a sharp decline in the number of working mothers, setting back gender equity employment gains for decades. Households headed by single women that are already financially insecure will struggle the hardest. We anticipate an increase in the number of housing insecure and unhoused families as single-breadwinner households lose income and struggle to find employment.
While much is worsening, there remains some hope. The COVID-19 pandemic could lead to more investment in the public health infrastructure, a development that would increase the health and wellbeing of people in the U.S. beyond the current crisis. Workers in low-wage positions such as grocery store employees, delivery drivers, janitorial staff, and others are gaining visibility as essential staff, which could translate into desperately needed healthcare and paid time-off benefits.
While it is necessary to focus on weathering the current crisis now, those of us who work in maternal health must be ready to protect it through research, advocacy, and practice in the near future. The pandemic gives us the unique opportunity to reassess the cracks in our society, and with vision and hard work, address deep-seated inequities. We must work together in this crisis and beyond to ensure that maternal health is not neglected.