Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a clinical syndrome caused by the coronavirus (COVID-19), became a pandemic following an outbreak of viral pneumonitis, first identified in Wuhan, Hubei, China. Coronaviruses are a large family of viruses that can cause a range of illnesses including the common cold, Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). When a new strain of coronavirus is discovered, it is called a ‘novel’ coronavirus because it is new and has not been previously identified (Centers for Disease and Prevention [CDC], 2020). The International Committee on Taxonomy of Viruses formally named the virus SARS-CoV-2 due to its genetic similarity to the virus that caused the SARS outbreak in 2003 (World Health Organization [WHO], 2020).
Coronaviruses are not just present in humans, with animals also having coronavirus-related illnesses. These viruses can mutate and be passed on to humans (Parrish et al, 2008). When the disease crosses over from animal to human, it is referred to as a ‘zoonotic spillover’ (Johnson et al, 2015). The resultant disease can be more severe because humans have not had to fight the illness before and the infection can amplify by human-to-human transmission with spread on a global scale, with COVID-19 being a prime example (Johnson et al, 2015). While not initially identified as a population at risk, pregnant woman may be more vulnerable to severe infection (Favre et al, 2020).
Evidence from previous viral outbreaks suggests a higher risk of unfavourable maternal and neonatal outcomes in this population (Alfaraj et al, 2019). Moreover, the associated policies developed as a result of the pandemic relating to social distancing and prevention of cross infection have led to important considerations specific to the field of maternal and neonatal health, and a necessity to consider unintended consequences for both the mother and baby (Buekens et al, 2020; Green et al, 2020a; 2020b; 2021). This review provides an overview of the current knowledge on COVID-19 and the implications for midwives. The aim is to address the current and emerging literature relating to COVID-19 in pregnancy and childbirth, and analyse key themes to inform midwifery practice. A second paper will cover the care implications relating to the newborn baby.
Method
An integrative review methodology was utilised for this paper as it enables a broad scope to facilitate a comprehensive understanding of COVID-19 infection in pregnancy. The literature was gathered using Arksey and O'Malley's (2005) five-step framework and, more recently, Levac et al's (2010) method of synthesising health evidence. COVID-19 has only been seen in 2020, therefore relevant and recent literature was easily identified using the terms:
- COVID-19 in pregnancy AND outcomes (8410)
- COVID-19 in babies/neonates AND outcomes (1670)
The search was then limited to:
- Full text in English (many of the earlier publications report results of women and babies in China because this is where COVID-19 is believed to have started)
- Pregnancy in women with SARS-CoV-2 and the disease process
- Guidelines for women with suspected SARS-CoV-2 infection
- Articles about possible intrauterine transmission
- Articles about possible transmission during labour and delivery
- Neonatal SARS-CoV-2 case reports.
Other resources have been used to inform the background, such as the maternal immune response and the specific characteristics of pregnancy. Updates from the WHO and the CDC have been utilised to ensure that any recommendations comply with current best evidence and practice.
Findings
The emerging themes for discussion, in the context of COVID-19 were the nature of the immune system in pregnant and newly birthed mothers, maternal risk, mode and timing of birth, care during pregnancy and childbirth and the transition to parenthood, including the implications for practice regarding the impact on maternal mental wellbeing.
The immune system in pregnant and newly delivered mothers
A fundamental feature of the immune system is to protect the host from pathogens. Pregnancy is a unique and complex immunological state with the maternal immune system facing challenges as it establishes and maintains tolerance to the allogeneic fetus, while maintaining the immune response to protect against microbial invasion (Liu et al, 2020a). A successful pregnancy relies on finely balanced immune modulation, immune responses to invasion and pro-inflammatory and anti-inflammatory stages (Nuriel-Ohayon et al, 2016).
During pregnancy, the maternal immunological states actively adapt and change with the growth and development of fetus. It moves from a pro-inflammatory state in the first trimester, which is beneficial at implantation and placentation to an anti-inflammatory state during the second trimester which is helpful for fetal growth. In the third trimester, it reaches a second pro-inflammatory state as it prepares for the onset of labour and delivery (Liu et al, 2020a).
The precise timing of immunological events in pregnancy has been labelled the ‘immune clock’ (Aghaeepour et al, 2017). An increase in the immune response makes the maternal immune system well prepared to defend the invasion of pathogens (Lui et al, 2020b). At the same time, there is a profound depression of cell-mediated immunity essential for fetal survival but this increases the women's susceptibility to viral infections (Zaigham and Andersson, 2020; Liu et al, 2020b).
Current evidence about the vertical transmission of SARS-CoV-2 is limited (Lui et al, 2020b). There is ample evidence that systemic maternal viral infections can affect pregnancies. During pregnancy, this can range from no effect to spontaneous miscarriage to fetal infection with congenital syndromes (Silasi et al, 2015). Previous studies have shown that SARS infection during pregnancy can lead to high rates of spontaneous miscarriage, premature birth and intrauterine growth restriction (Wong et al, 2004). This review found no evidence of vertical infection of SARS; however, the outcomes in the newborn were related to the maternal pregnancy complications (Wong et al, 2004) including hypoxemia and circulatory insufficiency as a result of infection (Gülçin, 2020; New South Wales Government and Clinical Excellence Commission, 2020). At present however, there is no evidence that SARS-CoV-2 is transmitted to the fetus.
SARS-CoV-2 infections are associated with a cytokine ‘storm’ (Huang et al, 2020). It is believed that when women are in the pro-inflammatory state of the first and third trimester, this cytokine-storm may induce a more severe inflammatory state (Lui et al, 2020b). It is suggested that this maternal hyperinflammation during pregnancy may affect fetal brain development leading to neuronal dysfunction (Mor et al, 2017) and may increase risk for neuro-developmental issues in the neonate (Martins-Filho and Tanajura, 2019). There is also growing evidence that pregnancy infection and enhanced expression of cytokines are associated with increased risk of autism spectrum disorder and schizophrenia (Estes and McAllister, 2016). Moreover, fever in a pregnant woman, the most common symptom of SARS-CoV-2 infection, could be associated with an increased attention-deficit/hyperactivity disorder in the offspring (Werenberg Dreier et al, 2016). There is a need for longitudinal research to evaluate this issue further with COVID-19, women and their children.
Maternal risk
The immune response of pregnant women needs to be effective particularly during SARS-CoV-2 infection because this is primarily a respiratory infection. There is the concern that SARS-CoV-2 infection could be more severe in pregnant women because of the pre-existing physiological factors that predispose them to respiratory infections; that is, basal atelectasis from gravid uterus, lower lung reserves and increased oxygen consumption (Qi, 2020; Zaigham and Andersson, 2020).
Current evidence suggests that pregnant women are not at greater risk then other adults for contracting SARS-CoV-2 (Rasmussen et al, 2020), despite the fact that pregnant women are more susceptible to respiratory infections, especially viral, due to these physiological adaptive changes that occurs during pregnancy (Yan et al, 2020) and immune adaptations required to accommodate the fetus. There is a suggestion from one case control study that pregnant women with other maternal complications may be at higher risk of contracting SARS-CoV-2 infections (Liu et al, 2020c) and another cohort study found that older women, those with higher body mass index or from ethnic minority groups, were at greater risk of hospital admission (Knight et al, 2020).
The evidence thus far indicates that woman infected with SARS-CoV-2 during pregnancy do not have adverse outcomes compared to those who are not pregnant (Ashokka et al, 2020; Gatta et al, 2020; Knight et al, 2020; Yan et al, 2020; Zaigham and Andersson, 2020; Chen et al, 2020b; 2020a). Most cases reported in these reviews, however, had only a short interval of time from diagnosis to birth and were in the third trimester. Therefore, the true impact of the infection cannot be determined. Generally, the women had mild infection, with 8% (nine) in one study reporting severe disease, one woman before birth and six after birth requiring non-invasive ventilation (Chen et al, 2020b).
Others have also reported small numbers of women who have progressed to more severe disease after birth (Zaigham and Andersson, 2020). Yan et al (2020) reported that 7% of pregnant women with severe disease required ICU admission while Knight et al (2020) found that out of 427 pregnant women admitted to hospital, 10% went to ICU and 1.2% died (Knight et al, 2020). Another case control study compared pregnant women with pneumonia (n=34) to a control group from a year earlier (n=121) (Liu et al, 2020c). Of the women with pneumonia, 70% had other maternal complications which was higher than the control group (32%) but no severe complications were noted (Liu et al, 2020c).
Overall, current evidence on pregnant women with SARS-CoV-2 pneumonia indicates that the condition is similar to non-pregnant adults (Yan et al, 2020; Zaaigham and Andersson, 2020; Chen et al 2020b). There is, therefore, no indication of increased risk of severe disease in pregnant women compared to the general population (Chen et al, 2020b).
Evidence from a case control study indicated that on admission however, most SARS-CoV-2-positive women did not have any symptoms (Liu et al, 2020c). Similarly, Yan et al (2020) reported that 23% of pregnant women reported to be asymptomatic with 78% of these being clinically diagnosed with SARS-CoV-2 pneumonia. This is of concern and highlights the need to strengthen infection control measures in maternity units including asymptomatic testing. In addition, while there is insufficient data to date in relation to pregnancy progression, the suggestion from women infected with SARS or MERS is that fetal growth surveillance after recovery from SARS-CoV-2 should be considered (Di Mascio et al, 2020).
Mode and timing of birth
Generally, the caesarean section rate is reported to be high in SARS-CoV-2 cases (Di Mascio et al, 2020; Gatta et al, 2020; Yan et al, 2020; Zaigham and Andersson, 2020; Chen et al, 2020a; Chen et al, 2020b). However, there appears to be no risk of transmission during vaginal delivery. Vaginal swabs of SARS-CoV-2-positive women have been shown to be negative (Yan et al, 2020). This was confirmed in a review of 655 SARS-CoV-2-positive pregnant women across 10 countries which compared vaginal and caesarean births (Walker et al, 2020). It has been suggested, however, that the threshold for caesarean birth is lower than usual to ensure infection control procedures are adhered to. Certainly, caesarean section should be considered for worsening maternal condition from SARS-CoV-2 (Ashokka et al, 2020; Qi et al, 2020). Based on evidence, SARS-CoV-2 infection cannot be considered as indication for caesarean section and should instead be determined by individual factors (Di Mascio et al, 2020; Walker et al, 2020).
In addition, risk of spontaneous miscarriage and spontaneous preterm birth does not appear to be increased (Yan et al, 2020). It would appear that the reported higher preterm birth rate (Zaigham and Andersson, 2020) is related to the consequence of elective intervention and is therefore iatrogenic (Di Mascio et al, 2020). In fact, a decreased incidence of preterm birth in Ireland and Denmark has been suggested, which may be attributed to the healthier lifestyle of women in isolation (Hedermann et al, 2020; Philip et al, 2020) as discussed by Green et al (2020b). The outcome of women with no or mild symptoms is unknown as yet. Concurrent consensus is that a SARS-CoV-2 diagnosis is not an absolute indication for an expedited birth (Qi et al, 2020). Decisions instead should be based on weighing up the condition of the woman and the health/viability of the fetus. There is no evidence of increased risk of fetal distress during labour for SARS-CoV-2-positive women compared to the general population (Liu et al, 2020c).
Currently, there is no evidence of vertical transmission during the third trimester of SARS-CoV-2-positive pregnant women, following amniotic and cord blood samples testing. These were found to be negative (Di Mascio et al, 2020; Yan et al, 2020) as were neonatal throat swabs and breastmilk samples (Chen et al, 2020a). There has been reported, however, one case of suspected vertical transmission from a SARS-CoV-2-positive women who had a caesarean section. As her neonate was found to be SARS-CoV-2-positive, vertical transmission cannot be excluded (Wang et al, 2020).
Care during pregnancy
Due to social isolation guidelines and forced quarantines during pregnancy, care has seen the reduction in face-to-face contact between the women and her caregiver (O'Connell et al, 2020; Richens et al, 2020) with a decrease in the previously recommended number of both antenatal and postnatal visits. This means that in the UK for instance, there are only six antenatal contacts for low-risk women compared to the previous nine or 10 (Richens et al, 2020). There has been a need to review how these appointments occur to minimise the contact time between the women and her caregiver. Appointments can be changed to virtual or telephone discussions instead of, or in combination with, a reduced time with the midwife assessing the women's blood pressure and fundal height.
These issues mean that vital tasks potentially get missed. For instance, it has been reported that the stillbirth rate has increased during this time (Ashish et al, 2020) suggesting that the ongoing assessment of the fetal wellbeing has been compromised under these circumstances. Therefore, it is essential to consider alternative arrangements; where possible, clinic visits could be undertaken in combination with ultrasound appointments (Richens et al, 2020). Midwives may undertake booking appointments over the phone or virtually with women coming into hospital for ultrasound, blood tests and baseline physical assessment.
When attending hospital-based clinics, there should be strict scheduling and timing of appointments to avoid gathering of women along with adherence to social distancing until the caregiver is ready to see the women. Unfortunately, this has meant women are requested to attend on their own for these visits without any partner or support person. Antenatal classes can also be conducted virtually or by other electronic means available. Even electronic fetal monitoring is occurring at home in the UK (Renfrew et al, 2020).
It has been identified that pregnant SARS-CoV-2-positive women feel insecure and anxious (O'Connell et al, 2020) and have an increased need for support and reassurance. A pregnant woman is anxious for herself and her baby, never mind the added risk of becoming infected with SARS-CoV-2. The imposed social isolation that has occurred in many countries during the COVID-19 pandemic has also come with its own issues. There are reports that the rates of domestic violence have tripled in China and rates of death from domestic violence have doubled in the UK since the COVID-19 pandemic (Richens et al, 2020). Suggestions have been that some face-to-face appointments be retained for those women identified at risk. The difficulty is being able to identify these women when antenatal visits are being undertaken virtually.
Consequences of the effect of such care on women have been demonstrated in an Australian survey of around 3 000 women (Cooper and King, 2020), indicating that women were seeking alternate care options because of the lack of face-to-face appointments, fear of contracting SARS-CoV-2, not being able to have support people with them and generally being unhappy with the care provided. As a result, women were attempting to access care options through private practicing midwives, birth centres or community care. The problem was, however, that women were unable to access these services (Cooper and King, 2020), pointing to the need for more midwifery models of care and access in the community.
Midwives face being overloaded both on an emotional level, as women require more reassurance and support, and on a practical level, as they take on new procedures for prevention and treatment of COVID-19 (O'Connell et al, 2020). In addition, midwives are overloaded due to staff shortages of between 20%–40% because of sickness and need to self-isolate (Renfrew et al, 2020). By necessity, the care has become focused on limiting and managing the spread of infection. Keeping up-to-date with the almost daily changes related to COVID-19 is a difficult reality of the current times that health professionals face. There is a risk of losing quality, individualised care for women and their families.
Care during childbirth
There are concerns expressed about the spread of infection during labour and birth because of the possibility of droplet contamination when women are forcefully exhaling during active labour (Qi et al, 2020). One suggestion has been to consider early epidural analgesia and that unmedicated natural labour be discouraged (Ashokka et al, 2020; Qi et al, 2020). In addition, there are reports that in Canada, SARS-CoV-2-positive women are being required to have epidurals in labour should there be a need for them to have a subsequent caesarean section under general anaesthetic (International Confederation of Midwives [ICM], 2020). There are also reports of increased interventions, inductions as well as caesarean births; all to minimise the potential infection risk (ICM, 2020; Renfrew et al, 2020).
Infection control precautions during labour include care being undertaken in a negative pressure isolation room, removing all unnecessary items from the room, full personal protective equipment (PPE) being worn by staff in attendance and women wearing masks (Straif-Bourgeois and Robinson, 2020; Qi et al, 2020; Green et al, 2021). There should also be restrictions on the number of people in the room to minimise movement between care locations and number of external visitors and care providers (Ashokka et al, 2020). This has resulted in women not having a partner or support people with them during labour. There are reports of women having birthed alone and unaccompanied (Murphy, 2020). There is also evidence of SARS-CoV-2 being detected in faeces, suggesting the possibility of an additional route of transmission from contaminated water during a water birth. Therefore, water birth may be discouraged in some settings for SARS-CoV-2-positive women (Straif-Bourgeois and Robinson, 2020).
Therefore, under the conditions of the COVID-19 pandemic, it is difficult to protect the essence of personalised, midwifery care at the same time as social distancing and wearing PPE, including masks and/or face shields. Moreover, women are receiving conflicting information as the general public are being advised to not attend hospital unless strictly necessary because the hospitals in countries like the UK and US are overwhelmed. There are reports that women are in fact being turned away from hospitals and subsequently dying (ICM, 2020). Women are therefore asking where they should go to birth their baby which further increases any existing anxiety. There has been a suggestion that women should be birthing in freestanding midwifery units, such as birth centres, which are available in some cities, (Rocca-Ihenacho and Alonso, 2020) such as New York, that is advocating for additional birth centres. In some countries, for instance the Netherlands, a suggestion has been made to open ‘pop-up’ birth centres in hotels near obstetric/maternity units. There is anecdotal evidence that more women are choosing to birth at home instead of hospital (Nelson and Romanis, 2020).
Transition to parenthood
The transition to parenthood and the early years of a child's life can be challenging and stressful for many mothers. With the onset of COVID-19, these parenting stressors can become amplified with mothers developing emotions, such as anxiety, failure and sadness, due to the inability to celebrate the birth of their baby, the often overwhelming feelings of responsibility to keep their baby safe, disrupted daily routines and in some cases limitations of basic liberties (ICM, 2020; Roy and Ples, 2020). These feelings may be exacerbated due to unclear or frequently changing recommendations about such issues as breastfeeding and physical contact with family and friends, and the necessity for mask wearing impeding communication (Green et al, 2021).
Anticipated social support provided by family, friends and/or attendance at new parenting groups is a key factor in the prevention of parental mental illnesses (Li et al, 2017). Social support has been identified as minimising concerns and strong negative emotions and improving the ability to cope with stress (Skurzak et al, 2015). Consequently, this support can assist in resolving family challenges that arise as an outcome of isolation (Hooge et al, 2014). Due to the physical distancing restrictions, much of the support parents normally receive is now not available, leaving parents to manage their physical tiredness and emotional distress without this much-needed safety net of social support.
To ameliorate this isolation and lack of social support, many early parenting health services have accelerated their use of digital technologies to provide health professional parenting support, assessment of the woman's and baby's health, and when necessary, intervention. While the use of video conferencing for parent consultations in some second- and third-tier early parenting health services has already been trialled (Bennett et al, 2020), these services have now been expanded to primary level child and family health services. In some services, this has resulted in individual consultations, parenting groups and combinations of face-to-face interactions and video conferencing (Fowler et al, 2020). Yet, as a recent report noted, parents still require face-to-face contact with a health professional as consultation through digital technologies alone were not always adequate (Fowler et al, 2019). Different communication skills have been identified as being needed when interacting through video conferencing as it can be difficult to develop a therapeutic relationship (Owen, 2020); identifying and responding to subtle changes in body languages or facial expressions can be challenging (Green et al, 2021). The other issues that need to be considered are privacy and the awareness of others that may overhear questions and responses likely to infringe privacy or place the parent at risk (Fowler et al, 2019).
Some residential services have maintained admissions under strict conditions. For example, Tresillian Family Care Centres in Australia with a well child residential unit has carefully followed the government health facility requirements (NSW Government and Clinical Excellence Commission, 2020). These requirements include a triage admission process at booking in and the day before admission to check the health of the parent and child; everyone entering the unit being asked a series of questions and having their temperature taken to ensure staff, parent, child and visitors were not unwell. If parents started to show signs of SARS-CoV-2 infection, they were referred to their doctor and sent home; parents and staff were required to physically distance and general play areas were closed. Universal infection control measures, handwashing and/or sanitising solution was easily accessible and increased cleaning of all equipment and physical environment as well as restriction on visitor numbers were put into place.
Conclusion
The COVID-19 pandemic has presented midwives with challenges when caring for mothers and babies. This review has presented what is currently known about SARS-CoV-2 and maternal health. The mother and baby should not be separated, and the mother needs to be able to participate in her baby's care and develop her mothering role. The WHO have made clear recommendations about the benefits of breastfeeding, even if the mother and baby dyad is SARS-CoV-2-positive, if they remain well. The complexities of not being able to access her usual support people means that the mother's mental health should be a priority during isolation and social distancing. It is vital to raise awareness of these important points. They, along with the benefits of breastfeeding and skin-to-skin contact on improving survival, may impart longer-term developmental benefits into early childhood. Therefore, midwives have a pivotal role and must continue to advocate strongly for mothers and babies throughout this pandemic.
Key Points
- The COVID-19 pandemic has presented midwives with challenges when caring for mothers and babies
- Preventing SARS-CoV-2 infection during pregnancy has possible implications for midwifery practice
- Mothers and babies should not be separated, and the mother needs to be able to develop her mothering role
- Breastfeeding should continue, even if the mother and baby dyad is SARS-CoV-2 positive
- The mother's mental health should be a main priority during isolation and social distancing
CPD reflective questions
- What are the challenges of caring for mothers during the COVID-19 pandemic?
- What is the impact of the measures to prevent COVID-19 infection on midwifery practice?
- How can midwives continue to help women take on their mothering role during the COVID-19 pandemic?
- What are the potential implications for breast-feeding support of women in the context of COVID-19?
- What is the potential impact of the COVID-19 restrictions on a mother's mental health?