In their recent systematic review of SARS-CoV-2 in pregnancy, Akhtar et al (2020) considered 22 studies, which identified 156 pregnant women with SARS-CoV-2 and 108 neonatal outcomes. The most common maternal/fetal complications included intrauterine/fetal distress (14%) and premature rupture of membranes (8%). Neonatal clinical manifestations of SARS-CoV-2 included shortness of breath (6%), gastrointestinal symptoms (4%), and fever (3%). There was no evidence to support vertical transmission of SARS-CoV-2 infection to the unborn child (Akhtar et al, 2020). Similarly, when Chen et al (2020) investigated nine women who developed SARS-CoV-2 pneumonia in late pregnancy, they failed to find evidence for intrauterine infection caused by vertical transmission.
Significantly, all nine women investigated by Chen et al (2020) had undergone caesareans, so the possibility of vaginal transmission could not be evaluated. Further, Chua et al (2020) cite previous studies of long-established human coronaviruses – first visualised in the 1960s (Almeida and Tyrrell, 1967) while studying common cold agents – demonstrating the possibility of materno-fetal transmission, with human coronavirus detected in both maternal respiratory and vaginal swabs: ‘As such, we should aim to reduce the exposure of newborns to all maternal bodily fluids’ (Chua et al, 2020). And in their retrospective analysis of 42 pregnant women from Northern Italy with confirmed SARS-CoV-2 infection, Ferrazzi et al (2020) suggest that vaginal delivery may be associated with a low risk of intrapartum SARS-CoV-2 transmission to the newborn.
The possibility of vaginal transmission of SARS-CoV-2 from mother to newborn is understood to be low
If caesareans are to be undertaken on SARS-CoV-2-infected women, to what extent might the wearing of personal protective equipment (PPE) affect the timing of the procedure? In a retrospective Spanish study, Cuerva et al (2020) investigated 42 caesareans on women with confirmed or suspected SARS-CoV-2 infection, and although operating room time was longer among the SARS-CoV-2 confirmed or suspected women (90 minutes versus 61 minutes for SARS-CoV-2-negative women), ‘[t]here were no significant differences in the operative time, transfer into the operating room to delivery time and skin incision to delivery time when wearing PPE in caesarean section’ (Cuerva et al, 2020).
So, is it acceptable during the COVID-19 pandemic to allow maternal request caesarean sections (MRCS)? Not according to Milton Keynes University Hospital, which has instituted new guidance to refuse all MRCS. This is cited by Romanis and Nelson (2020), who consider ethical aspects and note that critics of MRCS often raise the objection that because MRCS is riskier than vaginal delivery, MRCS is best avoided. However, Romanis and Nelson (2020) counter this by pointing out that the evidence adduced in favour of the objection uses data that conflate outcomes of MRCS and emergency caesarean (which is more common), thus introducing a confounding variable.
Romanis and Nelson (2020) are also clear that appropriately managed maternity departments, with robust PPE protocols, will minimise the number of hospitalised pregnant women who risk SARS-CoV-2 infection. A further telling observation from the authors is that because many home-birthing services were suspended in the UK during the pandemic, the inevitable corollary that women should attend hospital to give birth invites the inference that medical professionals consider that hospitals do not pose an unreasonable risk of infection.
But what do midwives think? When Dickson and Willett (1999) asked 135 practising female midwives what mode of delivery they would choose if they were pregnant for the first time with an uncomplicated singleton pregnancy, free of obstetric problems, 129 said they would have a vaginal delivery. Some 20 years later, midwives' views may have changed, but might there be a fundamental issue of patient autonomy and natural justice at the heart of this dilemma? After all, Romanis and Nelson (2020) cite evidence that demonstrates that failing to consider the patient's preferred choice in childbirth can precipitate significant birth trauma and mental health challenges that need subsequent and continuing treatment.
It seems reasonable to speculate that while the current COVID-19 pandemic is already posing significant mental health problems for many people, imposing a blanket ban on MRCS could be interpreted by some as a retrograde step. Yet at a time of scarce healthcare resources and talk of ‘a new normal’ in the face of the unfolding pandemic, perhaps it is inevitable that a utilitarian approach to ethics will colour our attitudes to what we consider to be the correct ethical approach towards the cultivation of civilised behaviour.