ArticlePDF AvailableLiterature Review

Obstetric challenges during COVID-19 pandemic: A narrative review



The severe acute respiratory coronavirus 2 (COVID-19) pandemic impacts the health of women at reproductive age in different ways, starting from pregnancy planning to post-delivery. This narrative review summarises the challenges to obstetric practice posed by the severe acute respiratory coronavirus 2 (COVID-19) pandemic. In this paper, we highlight the impacts of COVID-19 to obstetric practice globally and the efforts taken to address these challenges. Further study is critical to investigate the effects of COVID-19 on pregnancy, the outcome of COVID-19 positive pregnant women, and the safety of vaccination during pregnancy and breastfeeding.
Annals of Medicine and Surgery 71 (2021) 102995
Available online 2 November 2021
2049-0801/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
Obstetric challenges during COVID-19 pandemic: A narrative review
Ehab Helmy Abdelmalek Fahmy
, Boon Tat Yeap
, Dg Marshitah Pg Baharuddin
Mohsen M A Abdelhafez
, Win Win Than
, May Zaw Soe
, Firdaus Hayati
, Yeung Sing Chin
Obstetrics and Gynaecology Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
Department of Medical Education, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
Department of Obstetrics and Gynaecology, Sabah Women and Childrens Hospital, Kota Kinabalu, Sabah, Malaysia
Obstetric challenges
The severe acute respiratory coronavirus 2 (COVID-19) pandemic impacts the health of women at reproductive
age in different ways, starting from pregnancy planning to post-delivery. This narrative review summarises the
challenges to obstetric practice posed by the severe acute respiratory coronavirus 2 (COVID-19) pandemic. In this
paper, we highlight the impacts of COVID-19 to obstetric practice globally and the efforts taken to address these
challenges. Further study is critical to investigate the effects of COVID-19 on pregnancy, the outcome of COVID-
19 positive pregnant women, and the safety of vaccination during pregnancy and breastfeeding.
1. Introduction
The COVID-19 pandemic is a pivotal event that has created massive
confusion and disarray on a global scale. A result of the severe acute
respiratory syndrome coronavirus-2 (SARS-coV-2), this crisis has caused
immeasurable worldwide disruption of medical services, including
maternal health services. Health systems around the world have been
stressed and strained to the maximum due to the pandemics devastating
effect on delivering healthcare services, especially for pregnant women
[1]. COVID-19 related maternal deaths have been reported despite the
provision of good practice and continuous efforts of healthcare pro-
viders [2]. In view of this, a structured mechanism must be judiciously
implemented to achieve the global goal of safe pregnancy and childbirth
outcomes during this crisis [3]. Due to the COVID-19 pandemic, preg-
nant women have had reduced access to the utilisation of medical ser-
vices and facilities, which in turn has negatively impacted maternal and
child health [4].
2. Conception planning challenges
The emergence of the SARS-Cov-2 virus affects pregnancy outcomes
in various ways. Many women reported changes in behaviour towards
conception with some deciding to postpone pregnancy due to unem-
ployment and its consequent nancial and economic uncertainty. In
general, the COVID-19 pandemic has had a signicant inuence on
pregnancy planning decisions, most of which are related to maternal
health and pregnancy outcomes [5].
3. Assisted reproductive technology challenges
The COVID-19 pandemic caused an unprecedented strain on the
global healthcare system. In the wake of the pandemic, many countries
suggested discontinuing or halting non-essential healthcare including
assisted reproductive technology (ART) and in-vitro fertilisation (IVF) as
a trial to reduce the spread of SARS-CoV-2 infection [6]. Human
reproduction societies in general recommended the postponement of
embryo transfer of current cycles and the halting of new cycle initia-
tions. These recommendations required new evidence to be presented in
order to adjust assisted reproductive management [7].
Globally, 88.6% of 299 reproductive medicine clinics reported a
53.8% complete shutdown and 23.7% partial shutdown. In terms of IVF
case volume changes, 76.6% of clinics reported 75% reduction in fresh
cycles, 80% of clinics reported a 75% reduction in frozen cycles, and
73.6% of clinics reported a 75% reduction in IUI cases. 3.7% of clinics
reported no reduction in cases [8].
The COVID-19 pandemic also negatively inuenced IVF and ART. A
study showed that 62% of women undergoing infertility treatment de-
ferred their procedures due to lack of safe transportation, 20% of cases
* Corresponding author.
E-mail address: (B.T. Yeap).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage:
Received 15 September 2021; Received in revised form 18 October 2021; Accepted 28 October 2021
Annals of Medicine and Surgery 71 (2021) 102995
delayed treatment due to nancial reasons, and 9% of couples declined
due to fear of the pandemic [9].
Standard protocols should be generated and strictly implemented to
protect patients and laboratory staff against the consequences of COVID-
19 aerosol-mediated infection [10]. A proper plan is necessary to protect
gametes and embryos with strict changes in laboratory practice to
resume ART and IVF services [11].
4. Antenatal care challenges and role of telemedicine
A multinational study found a signicant decrease in maternal care
services during the pandemic as a result of reduced clinic hours [12].
Many healthcare workers (HCW) were deployed to COVID-19 in-
stitutions and vaccination centres as part of nationwide efforts to curb
the pandemic. In Malaysia during the lockdown and Enforced Movement
Control Order (EMCO) periods, the whole transportation hub was
affected with individuals only allowed to go out during specic times
and duration for medical emergencies and purchasing groceries. This
restriction affected access to elective antenatal visits [13]. The level of
maternal education, distance from maternal health clinics, and monthly
income were directly related to the reduced utilisation of maternal
healthcare clinics during the COVID-19 pandemic [14].
Utilisation of antenatal care services was markedly reduced by 87%
due to a prevailing fear among pregnant women of contracting COVID-
19 [15].
There were limited face-to-face management and interaction be-
tween healthcare providers and their pregnant patients. In some in-
stitutions, patient antenatal care was conducted via telemedicine to
minimise actual physical or face-to-face contact [16]. Anaesthetists for
instance assessed patients who were electively scheduled for caesarean
section by video calls, and obstetricians viewed patientsblood pressure
and sugar proles from home. Mothers who had received tele-education
from psychologists during the pandemic showed decreased incidences of
prenatal stress and anxiety [17]. However, several serious aspects such
as illiteracy, poverty, inadequate access to internet, and ethnic minority
must be considered as potential barriers for telecommunication [18].
The Stay-at-Home order during the pandemic lockdown resulted in
many women who were in abusive relationships to have less contact
with family members and friends who could have otherwise provided
protection and support against spousal or partner violence [19]. In this
context, telemedicine played a prominent role of providing continuous
support for victims to prevent any worsening of their physical, mental
and sexual health during the lockdown. In a nutshell telemedicine could
be an alternative form of basic antenatal care to reduce face-to-face
hospital visits and minimise cross infection risks during the pandemic.
The worsening pregnancy outcomes globally during the COVID-19
pandemic was related to the reduction in healthcare seeking and
healthcare provision [20]. A study showed that one-third of pregnant
women who did not have adequate antenatal care due to delay in
seeking healthcare during the lockdown and the fear of COVID-19
infection ended up with a 44.7% increase in pregnancy complications
[21]. In Canada, there was 37% elevated symptoms of depression and
anxiety among pregnant women who were concerned about the effect of
COVID-19 on themselves and the lives of their babies [22]. Although
COVID-19 virus mother-to-child transmission antenatally or during de-
livery and breastfeeding was unlikely, pregnant women with COVID-19
symptoms may have adverse outcomes compared to nonpregnant
women. Several studies supported the possibility of increased risk of
psychiatric problem and domestic violence during pregnancy and after
delivery [23].
5. Intrapartum challenges
COVID-19 infection during pregnancy has been associated with the
increased rate of caesarean section procedures [24]. This is due to the
need to reduce patient contact, especially those with reverse
transcription Polymerase Chain Reaction (rt-PCR) or rapid test kit (RTK)
positive results for COVID-19. A cohort study at a tertiary hospital in
Beijing reported the evidence of 11% increase in risk of premature
rupture of membranes and 14% increase in risk of fetal distress as well as
more women manifesting either inadequate or excessive weight gain
during the COVID-19 pandemic in China [25].
Hospital admission of pregnant patients with mild COVID-19 clinical
features requires appropriate approach by a multidisciplinary team for
proper management and favourable maternal and neonatal outcomes
[26]. Patients suspected or symptomatic of COVID-19 should be
promptly isolated while those who are conrmed of the infection should
be admitted in negative pressure rooms or isolation rooms with ltration
systems away from other patients [27]. In Malaysia, pregnant women
who are in the active phase of labour are screened for COVID-19 using
RTK antigen which is 82% sensitive compared to rt-PCR. HCW managing
these patients wear personal protective equipment (PPE) gear which
includes N95 face mask, face shield, gloves and apron in addition to
social distancing. The threshold to perform emergency caesarean section
is kept at a minimum to limit patient contact. There have been several
cases whereby medical centres in Malaysia had to perform perimortem
caesarean sections on dying mothers with severe COVID-19 to save their
unborn child.
6. Postpartum challenges
The mandatory implementation of strict infection control measures
in hospitals to minimise nosocomial COVID-19 infection may reassure
patients who are concerned about contracting the disease during hos-
pitalisation. Multiple studies have reported no signicant adverse out-
comes in the neonates of symptomatic COVID-19 positive mothers
compared to symptomatic COVID-19 negative mothers. Current guide-
lines for postpartum COVID-19 positive mothers prescribe the continu-
ation of breastfeeding supported by essential hygiene, hand sanitisation
and the wearing of medical face masks [28].
Worldwide, there is notable diversity in the severity of postpartum
psychological changes among women. A cross-sectional study in Torino,
Italy reported the high incidence of postpartum depression and post-
traumatic stress symptoms in women who delivered during the
COVID-19 pandemic [29]. However, in Israel, the post-partum risk for
depression was lower in women delivering during the pandemic
compared to women who did not [30].
The World Health Organisation (WHO) recommends skin-to-skin
contact breastfeeding to be continued for COVID-19 positive patients
[31]. Breastfeeding mothers should select appropriate locations such as
well-ventilated public lactation facilities with health security during the
COVID-19 pandemic [32]. Earlier contraception counselling and
completed consent forms are performed antenatally using electronic
methods as many patients would request for immediate discharge from
postnatal wards during the pandemic in the event of non-complication
deliveries [33].
7. Challenges of COVID-19 vaccination
It has been observed that pregnant women demonstrate hesitancy in
receiving the COVID-19 vaccination with a main concern being vaccine
safety during pregnancy [34]. On 10 June 2021, WHO recommended
that pregnant women be vaccinated whenever the benets of vaccina-
tion outweighed its potential risks. WHO additionally did not recom-
mend the discontinuation of breastfeeding among mothers who had
received COVID-19 vaccination. There is increasing evidence that
COVID-19 vaccines are safe in pregnancy with the rst dose to be
administered ideally between 14 and 33 weeks of pregnancy [35]. In
Malaysia, severe COVID-19 infections among pregnant women have
been associated with increased age and comorbidity. Maternal mortality
of COVID-19 infected pregnant women was 2.062% with the majority of
cases occurring among the unvaccinated [36]. Mega vaccination centres
E. Helmy Abdelmalek Fahmy et al.
Annals of Medicine and Surgery 71 (2021) 102995
were set up and vaccination made compulsory for pregnant women to
reduce mortality rates. Pregnant women in rural areas were not
excluded from this vaccination drive: in localities which were accessible
only by river, HCW were own in via helicopter to vaccinate them along
with other villagers using the single dose vaccine.
There is evidence of elevated SARS-CoV-2 Immunoglobulin G and A
(IgG and IgA) antibodies in the breast milk of vaccinated mothers
against the COVID-19 virus after one week of the initial dose which may
offer protection for their babies [37]. It was reported that 61.8% of
tested breast milk samples turned positive for antiSARS-CoV-2-specic
IgA antibodies at 2 weeks post-rst dose of vaccine and 86.1% positive
at 1 week post-second dose. AntiSARS-CoV-2-specic IgG antibodies
meanwhile remained low during the rst 3 weeks post vaccination but
subsequently increased to 91.7% at week 4 and 97% at weeks 5 and 6
[38]. This is benecial for breastfeeding mothers as these antibodies
may provide some COVID-19 protection to their baby. However, further
research must be conducted to verify the benets of vaccination for this
group of women.
8. Patient referral and transportation challenges
Obstetric emergency appropriate referral direction and patient
transportation should be provided to facilitate screening, isolation and
provision of optimal care for infected pregnant women at hospital fa-
cilities [1]. Ambulances transporting suspected or conrmed COVID-19
patients should be thoroughly cleaned, washed and disinfected
including the patient care cabin and driver cabin as well as the safe
disposal of PPE and used materials. This requires a strict professional
checklist to avoid related errors which may lead to increased trans-
mission of COVID-19 infection among healthcare workers and patients
9. Impact on healthcare workers
In China, healthcare workers were found to have psychosocial
problems during the COVID-19 outbreak which necessitated critical
attention and recovery programmes [40]. Lai et al. reported incidences
of 50.4% depressive symptoms, 44.6% anxiety, 71.5% distress and 34%
insomnia among healthcare workers during the pandemic in China [41].
Frontline healthcare workers reported experiencing inadequate sleep
and rest as a result of increased workloads. Symptoms of depression,
anxiety and distress due to the inability to obtain support from family
and friends were also reported. Nurses however had a positive response
to the moral and ethical challenges they encountered during the
pandemic [42]. In Malaysia, continuous online telemedicine psycho-
logical assistance is made available to all HCW. In addition, more HCW
from non-essential wards are deployed to assist in the care of patients
with COVID-19 and at vaccination centres. This has greatly reduced the
burden on other HCW and improved their quality of life.
A tertiary government hospital reported a signicant delay for both
decision-to-delivery interval and overall operative time due to obstacles
resulting from the enforcement of new safety measures for healthcare
providers and patients such as procedure preparation, anaesthesia, and
obstetrician factors during the pandemic [43]. Operating rooms were
required to implement specic preparations including infrastructure
modication, staff segregation and patient management according to
clinical recommendations and infection control strategies. The manda-
tory use of PPE signicantly prolonged operating time of urgent
caesarean section for COVID-19 suspected or conrmed patients [44].
Surgeons and anaesthetists reported reduced vision, tactile and con-
centration during obstetric procedures caused by the use of multi layers
of PPE. The Malaysian government allocated billions of ringgit on the
purchase of PPE and in raising the allowances of HCW during the
COVID-19 pandemic [45].
The Centre for Disease Control and Prevention (CDC) recommends
postponing elective surgical procedures, while emergency cases should
be managed without delay after COVID-19 status assessment with pro-
cedures to be conducted by skilled surgeons to shorten operating time
and minimise the risk of infection [46]. This recommendation in effect
limits the opportunity for training interns and students. Nevertheless,
various e-learning and social media platforms such as WhatsApp,
Instagram, Twitter and YouTube could be fully utilised to promote the
importance of PPE to protect healthcare workers against nosocomial
infection of the COVID-19 virus [47]. The rapid dissemination of up-
dates on guidelines and protocols on the constantly evolving COVID-19
virus is necessary to minimise risk of exposure to other patients and
healthcare workers.
10. Conclusion
The COVID-19 pandemic has resulted in an unprecedented health-
care crisis around the globe and very signicantly compromised ob-
stetric care with the antenatal, intrapartum and postpartum care of
pregnant women and mothers severely impacted. Nevertheless, various
efforts have been implemented by healthcare systems to support ob-
stetric services during the COVID-19 pandemic to reduce mortality rates.
Guidelines and clinical recommendations should be always based on
clinical evidences rather than individual expert consensus. Enforcement
of strict SOPs in the community setting is essential to reduce the inci-
dence of cross infection and as a means of reassuring patients to utilise
available health facilities. Concerted efforts must be put together to
update all integrated technologies and increase internet coverage to
full the need for patient follow-up and reduce mortality rates related to
Ethical approval
This narrative review does not need ethical approval.
Sources of funding
There are no funds received for this manuscript.
Author statement
Ehab Helmy Abdelmalek Fahmy (rst author).
Yeap Boon Tat (corresponding author).
Chin Yeung Sing (equal contributor).
Dg Marshitah Pg Baharuddin (co-author).
Mohsen M A Abdelhafez (co-author).
Win Win Than (co-author).
May Zaw Soe (co-author).
Firdaus Hayati (co-author).
This narrative review does not need a consent.
Registration of research studies
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2. Unique Identifying number or registration ID:
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E. Helmy Abdelmalek Fahmy et al.
Annals of Medicine and Surgery 71 (2021) 102995
Provenance and peer review
Not commissioned, externally peer reviewed.
Declaration of competing interest
There is no conict of interest in our manuscript.
The authors dedicate their gratitude to Faculty of Medicine and
Health Sciences, Universiti Malaysia Sabah, Malaysia.
[1] S.O. Ombere, Access to maternal health services during the COVID-19 pandemic:
experiences of indigent mothers and health care providers in kili county, Kenya,
Front. Sociol. 6 (2021 Apr 7) 53.
[2] J. Oluoch-Aridi, T. Chelagat, M.M. Nyikuri, J. Onyango, D. Guzman, C. Makanga,
L. Miller-Graff, R. Dowd, COVID-19 Effect on access to maternal health services in
Kenya, Front. Global Womens Health 1 (2020 Nov 26) 19.
[3] I.O. Ogunkola, Y.A. Adebisi, U.F. Imo, G.O. Odey, E. Esu, D.E. Lucero-Prisno III,
Impact of COVID-19 pandemic on antenatal healthcare services in Sub-Saharan
Africa, Publ. Health Pract. 2 (2021 Nov 1) 100076.
[4] A.K. Singh, P.K. Jain, N.P. Singh, S. Kumar, P.K. Bajpai, S. Singh, M. Jha, Impact of
COVID-19 pandemic on maternal and child health services in Uttar Pradesh, India,
J. Fam. Med. Prim. Care 10 (1) (2021 Jan) 509.
[5] A.C. Flynn, K. Kavanagh, A.D. Smith, L. Poston, S.L. White, The impact of the
COVID-19 pandemic on pregnancy planning behaviors, Womens Health Rep. 2 (1)
(2021 Mar 1) 7177.
[6] M. Simopoulou, K. Sfakianoudis, P. Giannelou, A. Rapani, C. Siristatidis, P. Bakas,
N. Vlahos, K. Pantos, Navigating assisted reproduction treatment in the time of
COVID-19: concerns and considerations, J. Assist. Reprod. Genet. 37 (11) (2020
Nov) 26632668.
[7] P.A. Monteleone, M. Nakano, V. Lazar, A.P. Gomes, H. de Martin, T.C. Bonetti,
A review of initial data on pregnancy during the COVID-19 outbreak: implications
for assisted reproductive treatments, in: JBRA Assisted Reproduction 24, 2020 Apr,
p. 219, 2.
[8] J. Tan, M.H. Dahan, M.B. Ata, S. Nair, Z. Shoham, S.L. Tan, Trends in fertility
practice during the COVID-19 pandemic: a global survey of 299 clinics
representing 228,500 IVF cycles, Fertil. Steril. 114 (3) (2020 Sep) e523.
[9] P.R. Jirge, S. Patwardhan, S.N. Jirge, D.A. Bhomkar, S.M. Chougule, A. Salpekar,
D. Modi, Resuming assisted reproduction services during COVID-19 pandemic: an
initial Indian experience, J. Hum. Reprod. Sci. 13 (4) (2020 Oct) 323.
[10] R. Maggiulli, A. Giancani, G. Fabozzi, L. Dovere, L. Tacconi, M.G. Amendola,
D. Cimadomo, F.M. Ubaldi, L. Rienzi, Assessment and management of the risk of
SARS-CoV-2 infection in an IVF laboratory, Reprod. Biomed. Online 41 (3) (2020
Sep 1) 385394.
[11] F. Choucair, N. Younis, A. Hourani, IVF laboratory COVID-19 pandemic response
plan: a roadmap, Middle East Fertil. Soc. J. 25 (1) (2020 Dec) 17.
[12] A. Semaan, C. Audet, E. Huysmans, B. Afolabi, B. Assarag, A. Banke-Thomas,
H. Blencowe, S. Caluwaerts, O.M. Campbell, F.L. Cavallaro, L. Chavane, Voices
from the frontline: ndings from a thematic analysis of a rapid online global survey
of maternal and newborn health professionals facing the COVID-19 pandemic, BMJ
Global Health 5 (6) (2020 Jun 1), e002967.
[13] W. Shin, T.R. Tan, P. Stoller, W. Yew, D. Lieo, Issues on the logistics challenges in
the pandemic period, J. Crit. Rev. 7 (8) (2020) 776780.
[14] K. Temesgen, N. Wakgari, B.T. Debelo, B. Tafa, G. Alemu, F. Wondimu, T. Gudisa,
T. Gishile, G. Daba, G.A. Bulto, B. Soboka, Maternal health care services utilization
amidstCOVID-19 pandemic in West Shoa zone, central Ethiopia, PLoS One 16 (3)
(2021 Mar 26), e0249214.
[15] E. Tadesse, Antenatal care service utilization of pregnant women attending
antenatal care in public hospitals during the COVID-19 pandemic period, Int. J.
Wom. Health 12 (2020) 1181.
[16] S. Meaney, S. Leitao, E.K. Olander, J. Pope, K. Matvienko-Sikar, The impact of
COVID-19 on pregnant womensexperiences and perceptions of antenatal
maternity care, social support, and stress-reduction strategies, Women Birth (2021
May 6).
[17] Y.A. Derya, S. Altiparmak, A.K. Emine, N. G ¨
Okbulut, A.N. Yilmaz, Pregnancy and
birth planning during COVID-19: the effects of tele-education offered to pregnant
women on prenatal distress and pregnancy-related anxiety, Midwifery 92 (2021
Jan 1) 102877.
[18] Roesch E, Amin A, Gupta J, García-Moreno C. Violence against Women during
Covid-19 Pandemic Restrictions.
[19] C. Pennanen-Iire, M. Prereira-Lourenço, A. Padoa, A. Ribeirinho, A. Samico,
M. Gressler, N.A. Jatoi, M. Mehrad, A. Girard, Sexual health implications of
COVID-19 pandemic, Sex. Med. Rev. 9 (1) (2021 Jan) 3.
[20] R. Townsend, B. Chmielewska, I. Barratt, E. Kalafat, J. van der Meulen, I. Gurol-
Urganci, P. OBrien, E. Morris, T. Draycott, S. Thangaratinam, K. Le Doare, Global
changes in maternity care provision during the COVID-19 pandemic: a systematic
review and meta-analysis, EClinicalMedicine 37 (2021 Jul 1) 100947.
[21] M. Goyal, P. Singh, K. Singh, S. Shekhar, N. Agrawal, S. Misra, The effect of the
COVID-19 pandemic on maternal health due to delay in seeking health care:
experience from a tertiary center, Int. J. Gynecol. Obstet. 152 (2) (2021 Feb)
[22] C. Lebel, A. MacKinnon, M. Bagshawe, L. Tomfohr-Madsen, G. Giesbrecht, Elevated
depression and anxiety symptoms among pregnant individuals during the COVID-
19 pandemic, J. Affect. Disord. 277 (2020 Dec 1) 513.
[23] B. Kotlar, E. Gerson, S. Petrillo, A. Langer, H. Tiemeier, The impact of the COVID-
19 pandemic on maternal and perinatal health: a scoping review, Reprod. Health
18 (1) (2021 Dec) 139.
[24] F. Di Toro, M. Gjoka, G. Di Lorenzo, F. De Seta, G. Maso, F.M. Risso, F. Romano,
U. Wiesenfeld, R. Levi-DAncona, L. Ronfani, G. Ricci, Impact of COVID-19 on
maternal and neonatal outcomes: a systematic review and meta-analysis, Clin.
Microbiol. Infect. (2020 Nov 2).
[25] M. Du, J. Yang, N. Han, M. Liu, J. Liu, Association between the COVID-19
pandemic and the risk for adverse pregnancy outcomes: a cohort study, BMJ Open
11 (2) (2021 Feb 1), e047900.
[26] M.J. Delahoy, M. Whitaker, A. OHalloran, S.J. Chai, P.D. Kirley, N. Alden,
B. Kawasaki, J. Meek, K. Yousey-Hindes, E.J. Anderson, K.P. Openo, COVID-NET
Surveillance Team. Characteristics and maternal and birth outcomes of
hospitalized pregnant women with laboratory-conrmed COVID-19-COVID-NET,
13 States, March 1-August 22, 2020, MMWR Morb. Mortal. Wkly. Rep. 69 (38)
(2020 Sep 25) 13471354.
[27] A.J. Stephens, J.R. Barton, N.A. Bentum, S.C. Blackwell, B.M. Sibai, General
guidelines in the management of an obstetrical patient on the labor and delivery
unit during the COVID-19 pandemic, Am. J. Perinatol. 37 (8) (2020 Jun) 829836.
[28] E.A. Wastnedge, R.M. Reynolds, S.R. Van Boeckel, S.J. Stock, F.C. Denison, J.
A. Maybin, H.O. Critchley, Pregnancy and COVID-19, Physiol. Rev. 101 (1) (2021
Jan 1) 303318.
[29] L. Ostacoli, S. Cosma, F. Bevilacqua, P. Berchialla, M. Bovetti, A.R. Carosso,
F. Malandrone, S. Carletto, C. Benedetto, Psychosocial factors associated with
postpartum psychological distress during the Covid-19 pandemic: a cross-sectional
study, BMC Pregnancy Childbirth 20 (1) (2020 Dec) 18.
[30] G. Pariente, O.W. Broder, E. Sheiner, T.L. Battat, E. Mazor, S.Y. Salem, T. Kosef,
T. Wainstock, Risk for probable post-partum depression among women during the
COVID-19 pandemic, Arch. Wom. Ment. Health 23 (6) (2020 Dec) 767773.
[31] R. Davanzo, A. Merewood, P. Manzoni, Skin-to-skin contact at birth in the COVID-
19 era: in need of help, Am. J. Perinatol. 37 (S 02) (2020 Sep) S14.
[32] Wang X, Han J, Lichtfouse E. Unprotected Mothers and Infants Breastfeeding in
Public Amenities during the COVID-19 Pandemic.
[33] H.E. Miller, A. Henkel, S.A. Leonard, S.E. Miller, L. Tran, K. Bianco, K.A. Shaw, The
impact of the COVID-19 pandemic on postpartum contraception planning, Am. J.
Obstetr. Gynecol. MFM 3 (5) (2021 Sep 1) 100412.
[34] S. Goncu Ayhan, D. Oluklu, A. Atalay, D. Menekse Beser, A. Tanacan, O. Moraloglu
Tekin, D. Sahin, COVID-19 vaccine acceptance in pregnant women, Int. J. Gynecol.
Obstet. (2021 May 1).
[37] J.K. Baird, S.M. Jensen, W.J. Urba, B.A. Fox, J.R. Baird, SARS-CoV-2 antibodies
detected in mothers milk post-vaccination, J. Hum. Lactation (2021 Jul 23),
[38] S.H. Perl, A. Uzan-Yulzari, H. Klainer, L. Asiskovich, M. Youngster, E. Rinott,
I. Youngster, SARS-CoV-2Specic antibodies in breast milk after COVID-19
vaccination of breastfeeding women, Jama 325 (19) (2021 May 18) 20132014.
[39] A.C. Alexandre, N.M. Galindo, M.A. Souza Silva, D.C. Silva Santos, J.
M. Alcoforado, D.B. Melo, Construction and validation of checklist for disinfecting
ambulances to transport Covid-19 patients, Revista Gaúcha de Enfermagem. (2021
Jun 18) 42.
[40] W.R. Zhang, K. Wang, L. Yin, W.F. Zhao, Q. Xue, M. Peng, B.Q. Min, Q. Tian, H.
X. Leng, J.L. Du, H. Chang, Mental health and psychosocial problems of medical
health workers during the COVID-19 epidemic in China, Psychother. Psychosom.
89 (4) (2020) 242250.
[41] A. Kakunje, R. Mithur, M. Kishor, Emotional well-being, mental health awareness,
and prevention of suicide: covid-19 pandemic and digital psychiatry, Archiv. Med.
Health Sci. 8 (1) (2020 Jan 1) 147.
[42] Y. Jia, O. Chen, Z. Xiao, J. Xiao, J. Bian, H. Jia, Nursesethical challenges caring for
people with COVID-19: a qualitative study, Nurs. Ethics 28 (1) (2021 Feb) 3345.
[43] M.E. dela Cruz-Tabanda, M.A. Bandola, A time-motion study on the operating
room processes among pregnant COVID-19 patients undergoing cesarean section in
a tertiary government hospital, Acta Med. Philipp. 55 (2) (2021 Apr 28).
[44] M.J. Cuerva, M. Carbonell, G. Martín Palumbo, S. Lopez Magallon, M. De La Calle,
J.L. Bartha, Personal Protective Equipment during the COVID-19 pandemic and
operative time in cesarean section: retrospective cohort study, J. Matern. Fetal
Neonatal Med. (2020 Jul 13) 14.
[45] A.U. Shah, S.N. Safri, R. Thevadas, N.K. Noordin, A. Abd Rahman, Z. Sekawi,
A. Ideris, M.T. Sultan, COVID-19 outbreak in Malaysia: actions taken by the
Malaysian government, Int. J. Infect. Dis. 97 (2020 Aug 1) 108116.
[46] A. Soltany, M. Hamouda, A. Ghzawi, A. Sharaqi, A. Negida, S. Soliman, A.
Y. Benmelouka, A scoping review of the impact of COVID-19 pandemic on surgical
practice, Ann. Med. Surg. (2020 Jul 9).
[47] S.J. Bajwa, M. Kurdi, N. Malhotra, Combating the COVID-19 battle with personal
protective equipment (PPE) armamentarium, J. Anaesthesiol. Clin. Pharmacol. 36
(Suppl 1) (2020 Aug) S133.
E. Helmy Abdelmalek Fahmy et al.
... There was a global shift to telemedicine to minimize actual physical or face-to-face contact [9]. Anesthetists for instance evaluated patients who were electively scheduled for caesarean section by video calls, and obstetricians monitored patients' blood pressure and sugar profiles remotely from home [11]. Prenatal stress and anxiety were less commonly observed in mothers who had received tele-education from psychologists throughout the pandemic [11]. ...
... Anesthetists for instance evaluated patients who were electively scheduled for caesarean section by video calls, and obstetricians monitored patients' blood pressure and sugar profiles remotely from home [11]. Prenatal stress and anxiety were less commonly observed in mothers who had received tele-education from psychologists throughout the pandemic [11]. However, a number of critical issues, including illiteracy, poverty, limited internet access, and ethnic minority must be taken into account as potential obstacles for telecommunication. ...
... Moreover, the health system should direct its approach to community-based service to reach neglected women and children who had not arrived at the facility and who cannot afford telemedicine due to poverty, and limited internet access [11]. It should also mobilize its workforce and resources to the lowest service delivery points and health posts [12]. ...
... Obstetricians, like all HCW, were faced with professional challenges but at the same time also faced challenges in their private lives [16]. They were not only double burdened but rather, the demands of each area increased the likelihood for those of the other: While they posed an additional risk of infection to their family members and close personal contacts, contagions spread from infected persons in the private environment could transmit the disease to the hospital and required quarantine measures [17]. ...
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Background: The COVID-19 pandemic and the necessary containment measures challenge obstetric care. Support persons were excluded while protection measures burdened and disrupted the professionals' ability to care and communicate. The objective of this study was to explore the first-hand experience of the impact of the COVID-19 pandemic on mothers, their partners, and obstetric professionals regarding birth and obstetric care in a university hospital. Methods: To answer the descriptive research questions, we conducted a qualitative content analysis using a data triangulation approach. We carried out 35 semi-structured interviews with two stratified purposive samples. Sample one consisted of 25 mothers who had given birth during the pandemic and five partners. Sample two included 10 obstetric professionals whose insights complemented the research findings and contributed to data validation. Participants were recruited from the study sample of a larger project on patient safety from two German university hospitals from February to August 2021. The study was approved by two ethics committees and informed consent was obtained. Results: Mothers complied with the rules, but felt socially isolated and insecure, especially before transfer to the delivery room. The staff equally reported burdens from their professional perspective: They tried to make up for the lack of partner and social contacts but could not live up to their usual professional standards. The exclusion of partners was seen critically, but necessary to contain the pandemic. The undisturbed time for bonding in the maternity ward was considered positive by both mothers and professionals. Conclusion: The negative effects of risk mitigation measures on childbirth are to be considered carefully when containment measures are applied.
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Background: The COVID-19 pandemic has had a profound impact on healthcare systems globally, with a worrying increase in adverse maternal and foetal outcomes. We aimed to assess the changes in maternity healthcare provision and healthcare-seeking by pregnant women during the COVID-19 pandemic. Methods: We performed a systematic review and meta-analysis of studies of the effects of the pandemic on provision of, access to and attendance at maternity services (CRD42020211753). We searched MEDLINE and Embase in accordance with PRISMA guidelines from January 1st, 2020 to April 17th 2021 for controlled observational studies and research letters reporting primary data comparing maternity healthcare-seeking and healthcare delivery during compared to before the COVID-19 pandemic. Case reports and series, systematic literature reviews, and pre-print studies were excluded. Meta-analysis was performed on comparable outcomes that were reported in two or more studies. Data were combined using random-effects meta-analysis, using risk ratios (RR) or incidence rate ratios (IRR) with 95% confidence intervals (CI). Findings: Of 4743 citations identified, 56 were included in the systematic review, and 21 in the meta-analysis. We identified a significant decrease in the number of antenatal clinic visits (IRR 0614, 95% CI 0486-0776, P<00001, I2=54.6%) and unscheduled care visits (IRR 0741, 95% CI 0602-0911, P = 00046, I2=00%) per week, and an increase in virtual or remote antenatal care (IRR 4656 95% CI 7762-2794, P<00001, I2=90.6%) and hospitalisation of unscheduled attendees (RR 1214, 95% CI 1118-1319, P<00001, I2=00%). There was a decrease in the use of GA for category 1 Caesarean sections (CS) (RR 0529, 95% CI 0407-0690, P<00001, I2=00%). There was no significant change in intrapartum epidural use (P = 00896) or the use of GA for elective CS (P = 079). Interpretation: Reduced maternity healthcare-seeking and healthcare provision during the COVID-19 pandemic has been global, and must be considered as potentially contributing to worsening of pregnancy outcomes observed during the pandemic.
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Background The COVID-19 pandemic has impacted on maternity care, supports and women’s mental health. Aim The aim of this study was to assess pregnant women’s satisfaction with antenatal care and social support and to examine stress-reduction strategies women used during the pandemic. Methods An online survey was conducted between June and July 2020. Pregnant women, aged over 18 years were recruited. The survey included closed and open-ended questions to assess women’s perceptions and satisfaction with their antenatal care, social support, and stress-reduction strategies. Descriptive statistics and multivariate analysis were used for quantitative analyses; qualitative content analysis was used for open-ended questions. Findings 573 pregnant women completed the survey. Women reported low levels of social support which was predicted by women’s mental health and demographic factors and was related to public health and maternity service restrictions. Women reported that restrictions implemented in the maternity services limited their face-to face interactions with healthcare professionals and meant their partners could not attend antenatal appointments or support them in the postpartum period in the maternity setting. The lack of information on COVID-19 and pregnancy meant women had greater uncertainty about pregnancy and birth. Discussion Our findings indicate how the lack of access to antenatal care and reduced perceived social support as a result of the restrictions implemented in response to the COVID-19 pandemic, potentially intensifies pregnancy specific stress. Conclusions There is a need for the provision of supportive care, both formally and informally, particularly with women who may be more vulnerable during a pandemic.
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Objective: To determine pregnant women vaccine acceptance and hesitancy attitudes toward COVID-19 vaccine. Methods: Three hundred pregnant women were surveyed face to face with forty questions. Socio-demographic characteristics, vaccination history, perception of risk for the COVID-19 pandemic, the impact of the COVID-19 pandemic, acceptance and attitude for future COVID-19 vaccination were prospectively evaluated. Results: Among all participants, 111 (37%) stated their intent to receive the vaccine if it were recommended for pregnant women. Most refusal reasons were; lack of data about COVID-19 vaccine safety in pregnant population and possibility of harm to the fetus. There was a weak positive correlation between COVID-19 vaccine acceptancy and number of school-age children. Pregnant women in first trimester expressed higher acceptance of COVID-19 vaccination than second and third trimester. Conclusion: The present study reported low acceptance of COVID-19 vaccination in a sample of pregnant women. Concern about vaccine safety was the major hesitancy reason. Identifying attitudes among priority groups will be useful to create vaccination strategies in the prevention current pandemic.
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COVID-19 has spread rapidly in Kenya and has not spared pregnant women. Evidence from Kenya shows that during the COVID-19 pandemic, health systems have been either stressed to their maximum capacity or are becoming overwhelmed. However, the population is advised not to attend hospital unless strictly necessary, and this advice seems to apply to all, including expectant mothers. There is a dearth of information on how poor expectant mothers with low bargaining power cope during COVID-19 in Kenya, which this study addresses for those in Kilifi County. This rapid qualitative study draws data from an extensive literature review and from interviews with 12 purposively selected mothers who were either expectant or had newborn babies during the pandemic in Kilifi County. Five matrons-in-charge of maternal health services and four traditional birth attendants were also interviewed via mobile phone. Data were analyzed thematically and are presented in a textual description. It emerged that expectant mothers feared attending hospitals for perinatal care due to the possibility of contracting COVID-19. Therefore, there was an increase in home deliveries with the assistance of traditional birth attendants (TBAs)/traditional midwives, who were also overwhelmed with women who sought their services. Since most causes of maternal morbidity and mortality can be prevented by prompt, suitable treatment by qualified health practitioners, the health officials interviewed recommended training and integration of TBAs in emergency healthcare responses to help during crises in MHS because they are trusted by their local communities. Notably, such integration of traditional midwives should be supported and should also include additional training and monetary incentives.
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The novel coronavirus (COVID-19) is an infectious disease caused by a newly discovered coronavirus. Despite strong efforts that have been taking place to control the pandemic globally, the virus is on the rise in many countries. Hence, this study assessed the maternal health care services utilization amidst the COVID-19 pandemic in West Shoa zone, Central Ethiopia. A community-based cross-sectional study was conducted among 844 pregnant women or those who gave birth in the last 6 months before the study. A multi-stage sampling technique was used to select the study participants. The data were collected through face-to-face interviews using a semi-structured questionnaire. Logistic regressions were performed to identify the presence of significant associations, and an adjusted odds ratio with 95%CI was employed for the strength and directions of association between the independent and outcome variables. A P-value of
Background The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has infected over 127 million people worldwide, with almost 2.8 million deaths at the time of writing. Since no lactating individuals were included in initial trials of vaccine safety and efficacy, research on SARS-CoV-2 vaccination in lactating women and the potential transmission of passive immunity to the infant through mother’s milk is needed to guide patients, clinicians, and policy makers on whether to recommend immunization during the worldwide effort to curb the spread of this virus. Research Aims (1) To determine whether SARS-CoV-2 specific immunoglobins are found in human milk after vaccination, and (2) to characterize the time course and types of immunoglobulins present. Methods A longitudinal cohort study of lactating women ( N = 7) who planned to receive both doses of the Pfizer-BioNTech or Moderna SARS-CoV-2 vaccine between December 2020 and January 2021 provided milk samples. These were collected pre-vaccination and at 11 additional timepoints, with the last sample at 14 days after the second dose of vaccine. Samples were analyzed for levels of SARS-CoV-2 specific immunoglobulins A and G (IgA and IgG). Results We observed significantly elevated levels of SARS-CoV-2 specific IgG and IgA antibodies in human milk beginning approximately 7 days after the initial vaccine dose, with an IgG-dominant response. Conclusions Maternal vaccination results in SARS-CoV-2 specific immunoglobulins in human milk that may be protective for infants.
OBJECTIVE The COVID-19 pandemic necessitated rapid adjustment of obstetrical delivery models including fewer antenatal appointments and increased use of telehealth. We hypothesized that an increase in telemedicine and a decrease in antepartum visits owing to the COVID-19 pandemic led to a decreased proportion of people with a postpartum contraception plan at the time of the birth-hospitalization admission and a reduced uptake of top-tier forms of contraception at birth-hospitalization admission and discharge, and the routine postpartum visit, which has otherwise been increasing in recent years.¹,² STUDY DESIGN A retrospective cohort study comparing a randomly selected sample of people giving birth at a large, tertiary referral center during a regional “shelter in place” order, March 16, 2020, to July 31, 2020, with a previously abstracted random sample of people delivering between November 1, 2017, and April 30, 2018, was conducted. This study was reviewed and approved by the Stanford University Institutional Review Board before its initiation. The study was powered to detect a 10% difference in the proportion of those arriving at birth-hospitalization with a contraceptive plan (power 80%, alpha 0.05). The final sample size included 586 people (318 in the pre-COVID cohort and 268 in the COVID cohort). Multivariable modified Poisson regression model was used to estimate the relative risk of arriving at birth-hospitalization with a contraceptive plan in pre-COVID vs COVID cohorts, adjusting for age, parity, insurance status, and delivery mode. Secondary outcomes included tier of contraception plan at admission, discharge, and 6 weeks postpartum (classified by World Health Organization Tiered-Effectiveness³), attendance at postpartum visit, and whether the postpartum visit was conducted via telehealth. Tiered effectiveness was used for this study's purposes because it was hypothesized that telehealth would mostly affect the provision of top-tier forms of contraception that require in-person initiation. Fisher exact test was used to compare the secondary outcomes. RESULTS For the 2 cohorts, the median age was 32 years (range, 17–48 years) and median parity was 1 (range, 0–6). The majority (78%) had private insurance and most commonly identified as non-Hispanic White (38%) and Asian (36%). Baseline demographics did not differ between the cohorts. At birth-hospitalization admission, a smaller proportion of people had a postpartum contraceptive plan in the COVID cohort than in the pre-COVID cohort (73.9% vs 99.4%, adjusted risk ratio, 0.87; 95% confidence interval, 0.84–0.91, P<.001). A smaller proportion of people had a plan for top-tier contraception among the COVID cohort compared with the pre-COVID cohort at both admission and discharge (46.0% vs 71.0%, P<.01 and 31.0% vs 37.9%, P=.05) (Figure). More than 80% of the people attended a routine postpartum visit in both cohorts (P=.30) with 17.7% being telehealth visits in the COVID cohort compared with telehealth not being offered pre-COVID. Among those who attended their postpartum visit, the proportion discharged with a plan for interval top-tier contraception that was fulfilled was high in both groups (76.3% pre-COVID vs 71.2% post-COVID, P=.56). CONCLUSION The study found a significant decrease in people arriving at birth-hospitalization with a contraception plan in the months following a COVID-19 “shelter in place” order when compared with the pre-COVID cohort. It is suspected that changes in the obstetrical service models indirectly deprioritized the most effective forms of postpartum contraception because sterilization requires a signed consent before birth-hospitalization and postplacental intrauterine devices require consent before delivery.⁴,⁵ Current state legislation requiring in-person signature to consent for federally funded sterilization remains a barrier. We found that fewer individuals left with top-tier contraception than with plan on admission, especially within the COVID cohort. In addition to clinical contraindications that arise during labor, which preclude placement of an intrauterine device in the postpartum setting, many patients requested an expedited discharge during the peak of the COVID-19 pandemic. As the prenatal care model continues, this transition to adopt virtual visits, reduce visit schedules, and expedite postpartum discharge, actualizing patients’ contraceptive plans is increasingly more dependent on early inpatient provision. Maternity care providers should consider initiating postpartum contraception counseling and completing mandatory consents earlier in the antenatal period. This study is inherently limited by its retrospective nature of review and additional qualitative studies may better characterize this trend in contraceptive uptake. In the meantime, obstetrical care providers should carefully evaluate institutional barriers to postpartum contraception during this movement to telehealth.
Objective. This study aims to determine time and motion in the operating room in emergent, urgent and scheduled cesarean section surgeries among pregnant COVID-19 patients. Methodology. A time and motion performance evaluation study was done by computing the following parameters: pre-induction time, pre-incision time, opening time, closing time, for both decision-to-delivery interval (DDI) and overall operative time. Results. During the study period, emergent DDI average was 2 hours and 38 minutes, emergent overall operative time was 1 hour and 31minutes, urgent DDI average was 3 hours and 51 minutes, and urgent overall operative time of 1 hour and 57 minutes. However, in both urgent and emergent cases, the recommended DDI of 30 minutes, and the average duration of 44.3 minutes for CS were not feasible. Conclusion. The COVID-19 pandemic has negatively affected the provision of surgical obstetric care and OR utilization. Due to the new safety protocol for healthcare workers and patients, there was a significant delay in DDI and overall operative time. The causes were preparation, anesthesia factors or obstetrician factors. Identifying modifiable obstacles may improve the DDI, overall operative time, and the quality of maternal and child birth care during this pandemic.
Background: Our understanding of how the coronavirus disease 2019 (COVID-19) pandemic has impacted decision-making for women planning to conceive is unclear. We aimed to investigate how the COVID-19 pandemic has influenced pregnancy planning behaviors. Methods: An online questionnaire of closed- and open-ended questions was utilized to capture pregnancy planning behaviors and reported behavioral changes during the COVID-19 pandemic in women planning pregnancy between January and July 2020. Closed-ended questions were analyzed quantitatively, and thematic framework analysis was utilized for open-ended responses. Results: A total of 504 questionnaires were included for analysis. The majority of respondents lived in the United Kingdom. Ninety-two percent of the women were still planning a pregnancy but over half (n = 267) reported that COVID-19 had affected their plans, with 72% of these (n = 189) deliberately postponing pregnancy. Concerns were predominantly over changes in antenatal care, but also fear of adverse effects of the virus on mother and baby. From the thematic analysis (n = 37), lack of services to remove contraceptive devices and provide fertility treatment were also cited. In contrast, 27% (n = 71) reported bringing their pregnancy plans forward; common themes included recalibration of priorities and cancelled or changed plans. Conclusions: The COVID-19 pandemic influenced pregnancy-planning behaviors with many women reporting postponement of pregnancy. These alterations in behavior could impact the health and wellbeing of women planning pregnancy while having important implications for health care services worldwide. Continued provision of family planning and fertility services should be ensured to mitigate the effect of future outbreaks or pandemics.