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 Children’s Hospital, Kota Kinabalu, Sabah, Malaysia
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.
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 pandemic’s devastating
effect on delivering healthcare services, especially for pregnant women
. COVID-19 related maternal deaths have been reported despite the
provision of good practice and continuous efforts of healthcare pro-
viders . 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 . 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 .
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 signicant inuence on
pregnancy planning decisions, most of which are related to maternal
health and pregnancy outcomes .
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 . 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 .
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 .
The COVID-19 pandemic also negatively inuenced 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: firstname.lastname@example.org (B.T. Yeap).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage: www.elsevier.com/locate/amsu
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 .
Standard protocols should be generated and strictly implemented to
protect patients and laboratory staff against the consequences of COVID-
19 aerosol-mediated infection . A proper plan is necessary to protect
gametes and embryos with strict changes in laboratory practice to
resume ART and IVF services .
4. Antenatal care challenges and role of telemedicine
A multinational study found a signicant decrease in maternal care
services during the pandemic as a result of reduced clinic hours .
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 specic times
and duration for medical emergencies and purchasing groceries. This
restriction affected access to elective antenatal visits . 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 .
Utilisation of antenatal care services was markedly reduced by 87%
due to a prevailing fear among pregnant women of contracting COVID-
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 . Anaesthetists for
instance assessed patients who were electively scheduled for caesarean
section by video calls, and obstetricians viewed patients’ blood pressure
and sugar proles from home. Mothers who had received tele-education
from psychologists during the pandemic showed decreased incidences of
prenatal stress and anxiety . However, several serious aspects such
as illiteracy, poverty, inadequate access to internet, and ethnic minority
must be considered as potential barriers for telecommunication .
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 . 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 . 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
. 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 . 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
5. Intrapartum challenges
COVID-19 infection during pregnancy has been associated with the
increased rate of caesarean section procedures . 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 .
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
. Patients suspected or symptomatic of COVID-19 should be
promptly isolated while those who are conrmed of the infection should
be admitted in negative pressure rooms or isolation rooms with ltration
systems away from other patients . 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
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 signicant 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 .
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 . However, in Israel, the post-partum risk for
depression was lower in women delivering during the pandemic
compared to women who did not .
The World Health Organisation (WHO) recommends skin-to-skin
contact breastfeeding to be continued for COVID-19 positive patients
. Breastfeeding mothers should select appropriate locations such as
well-ventilated public lactation facilities with health security during the
COVID-19 pandemic . 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
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 . On 10 June 2021, WHO recommended
that pregnant women be vaccinated whenever the benets 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 . 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 . 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 . It was reported that 61.8% of
tested breast milk samples turned positive for anti–SARS-CoV-2-specic
IgA antibodies at 2 weeks post-rst dose of vaccine and 86.1% positive
at 1 week post-second dose. Anti–SARS-CoV-2-specic 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
. This is benecial for breastfeeding mothers as these antibodies
may provide some COVID-19 protection to their baby. However, further
research must be conducted to verify the benets 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 . Ambulances transporting suspected or conrmed 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 . 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 .
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 . 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 signicant 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 . Operating rooms were
required to implement specic preparations including infrastructure
modication, staff segregation and patient management according to
clinical recommendations and infection control strategies. The manda-
tory use of PPE signicantly prolonged operating time of urgent
caesarean section for COVID-19 suspected or conrmed patients .
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 .
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 . 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 . 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
The COVID-19 pandemic has resulted in an unprecedented health-
care crisis around the globe and very signicantly 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
full the need for patient follow-up and reduce mortality rates related to
This narrative review does not need ethical approval.
Sources of funding
There are no funds received for this manuscript.
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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BOON TAT YEAP.
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 conict of interest in our manuscript.
The authors dedicate their gratitude to “Faculty of Medicine and
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