It’s been 6 weeks since our last COVID-19 and pregnancy newsletter.
In this edition of the Evidence Based Birth® COVID-19 Newsletter, we provide a new overview of the research on COVID-19 and pregnancy to date, focusing on key findings and recommendations.
**Feel free to forward this email to any friends, family, clients, or colleagues who might find it helpful. If you’re a healthcare worker, feel free to print this off to share at the nurse’s station! Anyone can subscribe to receive these updates by visiting evidencebasedbirth.com/covid19
The archive of this newsletter will also be posted on that page.
Today’s questions (answered in a Q&A section at the bottom of this email) include:
- Do we know what the overall pre-term birth rate was in the U.S. for 2020, and how that might compare to other years?
- I have a history of COVID in early pregnancy, and now my doctor is recommending that I take either aspirin or an anticoagulant for the rest of pregnancy. Is there any research on this?
To ask a question for consideration for future newsletters, submit your question here.
Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.
Research Update for January 21, 2021
- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19).
- Black, Latinx, and Indigenous pregnant and nonpregnant individuals are bearing the burden of the pandemic. These groups have higher rates of COVID-19 infections, hospitalizations, and severe outcomes, including death. Racial and ethnic health inequity in the pandemic is due to long-standing structural racism that put brown and black bodies at increased risk of getting sick and dying—not because of their biology, but because of discrimination in all sectors of life (aka systemic racism).
Numbers Update from Johns Hopkins University
As of January 21, 2021, there are over 96 million confirmed and probable cases of COVID-19 around the world. The highest number of cases is still in the U.S. (over 24 million), followed by India, Brazil, Russia, the United Kingdom, France, Italy, Turkey, Spain, and Germany.
- Pregnant people are advised to follow the same recommendations as nonpregnant people for avoiding exposure to SARS-CoV-2. These recommendations from the CDC include:
- Wear a mask over your nose and mouth
- Stay 6 feet away from people who don’t live in your household
- Avoid crowded places
- Meet in outdoor spaces when possible and try to ventilate indoor spaces
- Wash hands often
- Cover coughs and sneezes
- Clean and disinfect frequently touched surfaces
- Be alert for symptoms of COVID-19
- Prenatal and postpartum care appointments are important to keep; however, depending on your individual circumstances, it might be appropriate to delay some appointments or meet virtually. Elective ultrasounds are not recommended (ACOG, 2020). GBS screening is still recommended between 36 weeks, 0 days and 37 weeks, 6 days of pregnancy. However, some care settings are giving people instructions on how to self-collect a vaginal-rectal swab to limit in-person exposure during the pandemic (ACOG, 2020).
- Many vaccines are being developed, but pregnant and lactating individuals have been excluded from every trial so far. This means we do not have any data yet on the maternal, fetal, or newborn effects of these vaccines.
- The two vaccines that are currently authorized and recommended to prevent COVID-19 in the U.S. are the Pfizer-BioNTech vaccine and Moderna’s vaccine. They are both messenger RNA (mRNA) vaccines that do not contain live virus.
- In the U.S., the SMFM (12/21), ACOG (12/21), and the CDC (12/28) recommended that COVID-19 vaccines should not be withheld from pregnant/lactating individuals who are otherwise eligible for the vaccine and desire vaccination.
- In the U.K., on December 3, the Joint Committee on Vaccination and Immunization initially stated “JCVI favours a precautionary approach, and does not currently advise COVID-19 vaccination in pregnancy.” However, the JCVI updated their guidance on December 30 and now advises that “extremely clinically vulnerable” pregnant people discuss the option of vaccination with their care provider. They listed specific underlying conditions that put pregnant people at very high risk of experiencing serious complications from COVID-19:
- Solid organ transplant recipients
- Those with severe respiratory conditions including cystic fibrosis and severe asthma
- Those who have homozygous sickle cell disease
- Those receiving immunosuppression therapies sufficient to significantly increase risk of infection
- Those receiving dialysis or with chronic kidney disease (stage 5)
- Those with significant congenital or acquired heart disease
- The JCVI also now advises that pregnant health care workers and pregnant workers in residential facilities can discuss the option of vaccination. In addition, they say that breastfeeding/chestfeeding parents should be offered vaccination if they are otherwise eligible.
- The Royal College of Obstetricians & Gynecologists released a handout on COVID-19 vaccination and pregnancy (1/12/21). You can access this vaccine info sheet here.
Clinical Symptoms and Testing
- COVID-19 symptoms are similar between pregnant and nonpregnant patients; however, some symptoms with infection appear to be less common during pregnancy, especially fever.
- The U.S. PRIORITY study (Pregnancy CoRonavIrus Outcomes RegIsTrY) is an ongoing prospective nationwide study in the United States of pregnant or recently pregnant people. The most common symptoms in 594 symptomatic patients who tested positive for SARS-CoV-2 infection were cough (20%), sore throat (16%), body aches (12%), and fever (12%) (Afshar et al. 2020). Half of everyone had their symptoms resolve by 37 days, but symptoms lasted for ≥8 weeks in 25% of PRIORITY participants. In the PRIORITY study, 95% of participants were outpatients. The researchers are working to increase enrollment of Latina, Black, and Native American patients. These groups are currently underrepresented in the study (60% of study participants are White) which limits generalizability.
- Data from the CDC that included more hospitalized pregnant people with COVID-19 show increased rates of symptoms (50% had cough, 32% had fever, 37% had muscle aches, 24% has chills, 43% had headache, 26% head shortness of breath, 28% had sore throat, 14% had diarrhea, 20% had N/V, 8% had abdominal pain, 13% had runny nose, 22% had new loss of taste or smell, 14% had fatigue, 2% had wheezing, and 4% had chest pain (Zambrano et al. 2020).
- To treat fever and pain, acetaminophen (Tylenol) is preferred over NSAIDs (aspirin, ibuprofen/Motrin/Advil) because of possible worsening of symptoms with COVID-19 (Berghella and Hughes, 2020). Low-dose aspirin is still recommended for preeclampsia prevention as medically indicated, but may not be appropriate for pregnant and recently pregnant patients with suspected or confirmed COVID; care should be individualized (ACOG, 2020).
- Systematic reviews suggest that the majority of pregnant people who test positive during universal screening are without symptoms (most asymptomatic, but some pre-symptomatic) (Berghella and Hughes, 2020).
- COVID-19 diagnosis is done with nucleic acid amplification testing (NAAT), most commonly with a reverse-transcription polymerase chain reaction (RT-PCR) assay, which detects SARS-CoV-2 RNA from the upper respiratory tract. PCR tests are considered the gold standard for testing.
- Antigen tests are another type of diagnostic test. They detect a specific protein in SARS-CoV-2. Antigen tests are sometimes used first, but these tests are less sensitive, so negative antigen tests should usually be confirmed with NAAT if there is clinical suspicion of COVID-19. The majority of rapid tests so far have been antigen tests; however, there are now rapid PCR-based tests available in some care settings.
- False-negative tests are possible, so a negative RT-PCR test may need to be repeated if there is high clinical suspicion of COVID-19.
- False-positives have also been reported, but they are thought to be less common than false-negatives.
- There is no evidence that pregnancy increases the risk of getting infected with SARS-CoV-2
- Definitions according to the National Institutes of Health:
- Mild illness is considered symptoms without difficulty breathing or abnormal chest imaging
- Moderate illness is evidence of lower respiratory disease by clinical assessment or imaging and a saturation of oxygen (SaO2) ≥94% on room air at sea level.
- Severe illness is respiratory frequency >30 breaths per minute, SaO2 <94% on room air at sea level, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) < 300, or lung infiltrates >50%
- Critical illness is respiratory failure, septic shock, and/or multiple organ dysfunction
- Most (>90%) of people infected during pregnancy recover before they give birth and without needing hospitalization for COVID-19 (Berghella and Hughes, 2020). It is reassuring that the majority of pregnant people with COVID-19 either have no symptoms or mild illness that does not require hospitalization.
- However, pregnancy has been shown to increase the risk of severe or critical COVID-19. Given the growing evidence, the CDC now includes pregnant people in its “increased risk” category for COVID-19 illness. Unfortunately, the evidence in limited by large amounts of missing data on pregnancy status, race/ethnicity, and info on symptoms and underlying medical conditions (Zambrano et al. 2020).
- According to the latest U.S. surveillance data from the CDC (with over 400,000 symptomatic females of reproductive age), pregnant people with symptomatic COVID-19 appear to be at increased risk for ICU admission, invasive ventilation, extracorporeal membrane oxygenation (ECMO, a life support machine) and death compared to nonpregnant females of the same age with symptomatic COVID-19 (Zambrano et al. 2020). Still, the absolute risk of severe or critical illness and death for pregnant patients is low—even lower than the absolute risk of these outcomes during the H1N1 influenza pandemic (ACOG, 2020).
- In the CDC analysis, the absolute risks for invasive ventilation and death for pregnant versus nonpregant people of the same age and sex were 2.9 versus 1.1 per 1,000 and 1.5 versus 1.2 per 1,000, respectively. ECMO was used rarely but at a higher rate with pregnancy (0.7 versus 0.3 per 1,000). The absolute risk of ICU admission was noticeably increased (10.5 versus 3.9 per 1,000); however, this may be due in part to differences in care management during pregnancy.
- Remember, these absolute risks apply to people with lab-confirmed, symptomatic COVID-19; we don’t know if the risk of these outcomes is increased during pregnancy for people with asymptomatic infection or with symptoms that are so mild they do not seek medical care.
- Risk factors for severe or critical COVID-19 during pregnancy are similar to the risk factors in the general population (Westnedge et al. 2021). They include age ≥35 years, BMI ≥30, hypertension, and diabetes (preexisting and gestational) (Allotey et al. 2020; ACOG, 2020).
- Importantly, Black and Hispanic individuals who are pregnant are disproportionately affected by COVID-19—not because of their biology, but because of systemic racism creating inequitable opportunities for health.
- Timing of birth with COVID-19 should be individualized. Importantly, COVID-19 infection is not an indication for Cesarean, induction, or operative vaginal birth. When possible, it’s best to wait to give birth until after testing negative. Then, there is less chance of passing the infection to health care workers and to the newborn in the postpartum period.
- However, people with term pregnancies who have mild COVID-19 may wish to give birth sooner rather than later to avoid the risk of giving birth with more severe COVID-19 (should the disease worsen).
- Severely ill patients at least 32 weeks of pregnancy with COVID-19 pneumonia may benefit from early birth. But it’s not clear whether giving birth improves the birthing person’s respiratory disease (Berghella and Hughes, 2020).
- Maternal COVID-19 is linked to an increased risk of Cesarean. A report from the UK Obstetric Surveillance System (UKOSS) on pregnant people admitted to the hospital with confirmed COVID-19 in the UK found that 59% of people gave birth by Cesarean (Knight et al. 2020). About half of these were for maternal or fetal compromise and half were for other obstetric reasons (e.g., progress in labor, planned repeat Cesarean).
- A large systematic review estimated that about 65% of pregnant people with suspected or confirmed COVID-19 gave birth by Cesarean (Allotey et al. 2020). Many of the studies in this review (24/77) came from China, where the Cesarean rate with COVID-19 was very high early in the pandemic.
- U.S. surveillance data of pregnant people with laboratory-confirmed SARS-CoV-2 infection reported that among nearly 4,000 birthing people, the overall Cesarean rate was 34%, which is slightly higher than the U.S. Cesarean rate in 2019 (32%) (Berghella and Hughes, 2020).
- Wider implications of the pandemic for maternal health include increased risk of mental health distress and intimate partner violence. Care providers should be on heightened alert for these issues and look for ways to help clients manage stress, anxiety, and depression.
- Maternal COVID-19 has been linked to an overall increased risk of preterm birth, although individual countries have reported seeing decreased rates of preterm birth or no change in preterm birth rates.
- A systematic review of 77 studies from more than a dozen different countries, including over 11,000 pregnant and recently pregnant people with suspected or confirmed COVID-19, estimated that about 17% of births were preterm (Allotey et al. 2020). This was a three times greater risk of preterm birth with COVID-19 compared to those without the disease. However, most of these preterm births were medically caused (iatrogenic). The spontaneous preterm birth rate was only 6%, which is similar to the rate observed before the pandemic. It’s thought that complications from COVID-19 (e.g., pneumonia) increase the risk of Cesarean and preterm birth because providers intervene in hopes of improving the maternal respiratory condition. However, there is no evidence that planned early birth improves maternal outcomes with severe or critical COVID-19 (Berghella and Hughes, 2020).
- U.S. surveillance data of pregnant people with laboratory-confirmed SARS-CoV-2 infection reported that among 3,912 live births with known gestational age, 12.9% were preterm (<37 weeks) (Woodworth et al. 2020). This rate is higher than the reported 10.2% among the general U.S. population in 2019. Please see the Q&A section at the bottom of this newsletter for more discussion of pre-term birth rates during the pandemic.
- The U.S. PRIORITY study has, so far, not detected a difference in poor outcomes, including preterm birth, NICU admission, and respiratory disease, between infants (n=263) born to birthing parents testing positive (n=179) versus those testing negative (n=84) (Flaherman et al. 2020). A study with more racial and ethnic diversity also did not detect a difference in poor outcomes (using a combined outcome of preterm birth, severe preeclampsia, or Cesarean for abnormal GHR) by maternal COVID-19 status (Adhikari et al. 2020).
- There is no evidence suggesting an increased risk of congenital anomalies or any problems with the baby’s development.
- There is also no evidence suggesting that infection in early pregnancy increases the risk of miscarriage. (Data on first and second trimesters are limited.)
- Vertical transmission (transmission from the pregnant person to the baby before or during birth) has been reported in a few cases but it is thought to be rare. Researchers still do not understand the mechanisms by which vertical transmission occurs (Westnedge et al. 2021). A few placental infections and very early newborn infections have been reported; however, most placentas studied so far had no evidence of infection. Importantly, there is no evidence that the risk of vertical transmission is affected by mode of birth, method of feeding or rooming in. The vast majority (over 95%) of newborns born to infected parents have been asymptomatic or with only mild infection at birth. It is reassuring that severe or critical COVID-19 is rare with newborns (Westnedge et al. 2021).
- A large U.S. observational study found that the rate of early newborn infection among infants born to a parent who tested positive was 3%; most of the infected babies were born to parents with no symptoms or mild symptoms (Adhikari et al. 2020).
- There is no evidence that the risk of stillbirth increases with COVID-19 infection; however, the risk does appear to increase among patients hospitalized with a COVID-19 infection.
- Analysis of hospitalization data from England did not show an increase in stillbirths in England during the pandemic when compared with the same months in the previous year (Stowe et al. 2020).
- In the U.S., data from the CDC show a higher stillbirth rate among pregnant people hospitalized with COVID-19 compared to the overall population of pregnant people with lab-confirmed infection (3% versus 0.4%) (Panagiotakopoulos et al. 2020; Woodworth et al. 2020). For comparison, the overall rate of stillbirth in the U.S. is 0.6%. The increase in stillbirth among hospitalized COVID-19 patients may be related to maternal illness, medical intervention to treat COVID-19, and/or disruptions in prenatal care during the pandemic.
- There have been reports of problems with placental function from COVID-19 infection. However, more data is needed before we know how widespread a problem this is, and whether it’s clinically significant.
- Corticosteroid use to help prevent preterm birth is likely safe for pregnant people with COVID-19, and corticosteroid use for severe or critical maternal COVID-19 may also be beneficial (Westnedge et al. 2021).
- ACOG recommends that dexamethasone, a corticosteroid, be used for pregnant people with COVID-19 who are receiving supplemental oxygen or are mechanically ventilated, and that dexamethasone should not be withheld for treatment of COVID-19 due to pregnancy status.
- Similarly, UpToDate guidance for clinicians advises that “In pregnant women who meet criteria for use of glucocorticoids for maternal treatment of COVID-19 and also meet criteria for use of antenatal corticosteroids for fetal maturity, we suggest administering the usual doses of dexamethasone (four doses of 6 mg given intravenously 12 hours apart) to induce fetal maturation and continue dexamethasone to complete the course of maternal treatment for COVID-19 (6 mg orally or intravenously daily for 10 days or until discharge, whichever is shorter).”
- The evidence for dexamethasone treatment comes from the RECOVERY trial, a large, multicenter, RCT for patients hospitalized with COVID-19 in the U.K. (RECOVERY Collaborative Group et al. 2020). The trial showed that dexamethasone resulted in lower 28-day mortality among people receiving either mechanical ventilation or oxygen but not among those receiving no respiratory support. Even though only six pregnant people were included in the trial, guidance supports dexamethasone for use with infected pregnant people who are receiving supplemental oxygen or are mechanically ventilated because of possible life-saving benefits.
- Pregnancy is a hypercoagulable state (meaning there is an increased tendency toward blood clotting), so people who are pregnant or in the postpartum period have increased risk of thromboembolism (a blood clot that is carried by the blood stream and plugs a blood vessel) compared with nonpregnant people (ACOG, 2020). COVID-19 is also linked to increased blood clotting and increased risk of thromboembolism, especially in ICU patients. Therefore, recommendations are that pregnant patients hospitalized with severe or critical COVID-19 should be treated with prophylactic-dose anticoagulation, if there are no contraindications to its use (ACOG, 2020; Berghella and Hughes, 2020). Clinicians should also have a low threshold for investigating possible thromboembolic events in COVID-19 patients during pregnancy and postpartum (Westnedge et al. 2021). Please see the Q&A section at the bottom of this newsletter for more discussion of anticoagulant drugs.
- Remdesivir, an antiviral medication, is recommended for pregnant patients who would otherwise be candidates for the treatment. It has been used with severely ill pregnant patients without causing harm to the fetus (Berghella and Hughes, 2020).
- ACOG guidelines suggest, “In both the inpatient and outpatient settings, it is recommended that the number of visitors be reduced to the minimum necessary, for example, those essential for the pregnant individual’s well-being (emotional support persons).” Importantly, they say, “Labor, delivery, and postpartum support may be especially important to improve outcomes for individuals from communities traditionally underserved or mistreated within the health care system. In considering visitation policies, institutions should be mindful of how restrictions might differentially and negatively affect these communities, which in many areas are also disproportionately affected by COVID-19.”
- Professional guidelines acknowledge that it may not be feasible to wear a mask during labor, especially during second stage labor (ACOG, 2020). Wearing a mask could make pushing difficult and forceful exhalation may also make the mask significantly less effective. For this reason, those caring for birthing people should use appropriate PPE.
- Delayed cord clamping is still best practice when the birthing parent has COVID-19 (ACOG, 2020). The cord should remain unclamped for up to five minutes or when cord pulsation ceases. There is no evidence that delayed cord clamping increases the risk of giving the virus to the baby, and there are substantial known risks to early cord clamping. The care provider should wear appropriate PPE.
Rooming in and Infant Feeding
- There are many established benefits to rooming in, including increased success breastfeeding and parent-infant bonding. Studies have not found a difference in the rate of transmission when newborns are separated from infected parents versus kept together in the same room. Guidelines now state that newborns should “ideally” be kept together with their infected parent, and that “Decisions about temporary separation should be made in accordance with the mother’s wishes.” (ACOG, 2020).
- Birthing parents with COVID-19 should be encouraged to breastfeed/chestfeed, but should wear PPE (Westnedge et al. 2021). It is not known whether the virus can be transmitted through breastmilk. One case report detected SARS-CoV-2 RNA in breastmilk, but the viral particles may not have been infectious; most breastmilk samples from positive parents have been negative.
- Healthy, uninfected birthing parents and newborns are advised to consider early hospital discharge after birth (after 1 day with uncomplicated vaginal births and after 2 days with Cesarean births depending on recovery status) (ACOG, 2020).
Professional Guidance and Clinical Recommendations
- Several professional organizations have issued guidance on pregnancy issues during the pandemic. You can access professional guidance at acog.org, SMFM.org, and rcog.org.uk.
- Also, UpToDate.com has made their COVID-19 content free. They have a page devoted to COVID-19 and pregnancy.
Q & A Section
Question: Do we know what the overall pre-term birth rate was in the U.S. for 2020, and how that might compare to other years?
Answer: No, the most recent year of birth data from the U.S. Centers for Disease Control (CDC) is 2019. The CDC National Center for Health Statistics (NCHS) released their latest data brief (No. 387) in October 2020 with key findings from the 2019 data. The overall rate of preterm birth rose to 10.23% in 2019, an increase over the 2018 rate of 10.02%.
We don’t know yet if the U.S. preterm birth rate rose in 2020, although early findings suggest that it may have. The CDC has been collecting info on pregnancy and infant outcomes among pregnant people with lab-confirmed infections through SET-NET (the Surveillance for Emerging Threats to Mothers and Babies Network). Among 3,912 live births to infected parents, 12.9% were preterm (<37 weeks) (Woodworth et al. 2020). As you can see, this is higher than the U.S. preterm birth rate among the general population in 2018 and 2019, and if enough pregnant people experienced infection, this could possibly contribute to a higher preterm birth rate in 2020.
Individual studies have been mixed on whether they found a difference in preterm births during the pandemic. Decreases in preterm births have been reported in several European countries, sometimes alongside increases in stillbirth. But even within countries, the impact of the pandemic on preterm birth likely varies in sub-populations based on social and economic factors.
Question: I have a history of COVID in early pregnancy, and now my doctor is recommending that I take either aspirin or an anticoagulant for the rest of pregnancy. Is there any research on this or guidelines to support this practice?
Answer: We have not seen any evidence to support the prophylactic (preventative) use of aspirin among pregnant people with a history of COVID-19 earlier in pregnancy but without other clinical indications for the treatment. However, recommendations mention that aspirin should continue to be offered to pregnant and postpartum parents as medically indicated during the pandemic (ACOG, 2020). Perhaps your doctor is recommending aspirin for a non-COVID related medical indication? Low-dose aspirin is most commonly recommended during pregnancy to pregnant people at moderate to high risk of preeclampsia.
As we mentioned earlier in this newsletter, aspirin may not be appropriate for pregnant people with suspected or confirmed COVID-19 because of evidence that NSAIDs (including aspirin) potentially worsen COVID symptoms.
We are also not aware of any evidence (yet) to support thromboprophylaxis with anticoagulants among pregnant people with a history of COVID-19 earlier in pregnancy but without other clinical indications for the treatment. People with active COVID-19 infections during pregnancy (particularly with severe or critical disease) may benefit from anticoagulation treatment, but the treatment is only recommended for those who are hospitalized because of their COVID-19 disease (Berghella and Hughes, 2020). People hospitalized because of their COVID-19 infections may be advised to continue thromboprophylaxis for 10 days following hospital discharge or longer if they remain ill from their infection. But if you had COVID-19 in early pregnancy and it did not require hospitalization, then your doctor may be recommending anticoagulants because you have non-COVID related risk factors for blood clots (also known as venous thromboembolisms, or VTEs).
Whenever care providers recommend intervention, you should always feel empowered to ask them if their advice is based on a research study, a clinical guideline, or their professional medical opinion. Also, keep in mind that as the pandemic progresses, new research may come out that provides us with new insights on this topic.
This concludes the research update for January 21, 2021. We hope you found it helpful! Our next research update will come out in March 2021.
If you would like to submit a follow-up question for our consideration to include in upcoming newsletters, you can submit your question here.
The Research Team at Evidence Based Birth®
Adhikari, E. H., Moreno, W., Zofkie, A. C., et al. Pregnancy Outcomes Among Women With and Without Severe Acute Respiratory Syndrome Coronavirus 2 Infection. JAMA Netw Open. 2020;3(11):e2029256. Click here.
Afshar, Y., Gaw, S. L., Flaherman, V. J., et al. (2020). Clinical Presentation of Coronavirus Disease 2019 (COVID-19) in Pregnant and Recently Pregnant People. Obstet Gynecol. 2020 Dec;136(6):1117-1125. Click here.
Allotey, J., Stallings, E., Bonet, M., et al… for PregCOV-19 Living Systematic Review Consortium (2020). Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ (Clinical research ed.), 370, m3320. Click here.
American College of Obstetricians and Gynecologists (2020). COVID-19 FAQs for obstetricians-gynecologists, obstetrics. Washington, DC: ACOG. Available at: https://www.acog.org/clinical-
information/physician-faqs/ covid-19-faqs-for-ob-gyns- obstetrics. Retrieved January 7, 2020.
Berghella, V. and Hughes, B. (2020). UpToDate: Coronavirus disease 2019 (COVID-19): Pregnancy Issues and Antenatal care. Click here.
Flaherman, V. J., Afshar, Y., Boscardin, W. J., et al. (2020). Infant Outcomes Following Maternal Infection With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): First Report From the Pregnancy Coronavirus Outcomes Registry (PRIORITY) Study, Clinical Infectious Diseases, ciaa1411. Click here.
Knight, M., Bunch, K., Vousden, N., et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ 2020; 369:m2107. Click here.
Panagiotakopoulos, L., Myers, T. R., Gee, J., et al. (2020). SARS-CoV-2 Infection Among Hospitalized Pregnant Women: Reasons for Admission and Pregnancy Characteristics — Eight U.S. Health Care Centers, March 1–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1355–1359. Click here.
RECOVERY Collaborative Group, Horby, P., Lim, W. S., et al. (2020). Dexamethasone in Hospitalized Patients with Covid-19 – Preliminary Report. N Engl J Med. 2020 Jul 17:NEJMoa2021436. Click here.
Stowe, J., Smith, H., Thurland, K., et al. (2020). Stillbirths During the COVID-19 Pandemic in England, April-June 2020. JAMA 2020. Click here.
Wastnedge, E. A. N., Reynolds, R. M., van Boeckel, S. R., et al. (2021). Pregnancy and COVID-19. Physiol Rev. 2021 Jan 1;101(1):303-318. Click here.
Woodworth, K. R., CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team, COVID-19 Pregnancy and Infant Linked Outcomes Team (PILOT), et al. (2020). Birth and Infant Outcomes Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancy – SET-NET, 16 Jurisdictions, March 29-October 14, 2020. MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1635-1640. Click here.
Zambrano, L. D., Ellington, S., Strid, P., CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team, et al. (2020). Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status – United States, January 22-October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1641-1647. Click here.
Do site da Febrasgo
Com a aprovação de vacinas contra COVID-19 pela Agencia Nacional de Saúde (ANVISA) a Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo) emite essa recomendação em relação à vacinação de
gestantes e lactantes, com as vacinas aprovadas para uso emergencial no Brasil.
O objetivo da vacinação nesse momento é a redução da morbimortalidade causada pelo novo coronavírus, bem como a manutenção do funcionamento da força de trabalho dos serviços de saúde e a manutenção do funcionamento da força de trabalho dos serviços de saúde e a manutenção do funcionamento dos serviços essenciais. [Informe Técnico MS]
A ANVISA liberou para uso emergencial as seguintes vacinas:
1) Laboratório Sinovac (Coronavac) para uso em adultos maiores de 18 anos em regime de duas doses com intervalo de 2 a 4 semanas
2) Laboratório Serum (COVISHIELD) para uso em adultos maiores de 18 anos em regime de duas doses.
Como essa vacina não se encontra disponível, a Febrasgo estará atualizando essas recomendações com essa formulação, assim que for incorporada ao programa Nacional de Imunizações do Ministério da Saúde do Brasil.
O Ministério da Saúde iniciará a campanha nacional de vacinação contra a covid-19 com um total de 6 milhões de doses da vacina Sinovac (Butantan) que tem indicação de duas doses para completar o esquema vacinal (intervalo de 2 a 4 semanas entre elas) e o percentual de perda operacional de 5%, estima-se vacinar nesta primeira etapa cerca de 2,8 milhões de pessoas, priorizando os grupos que seguem: trabalhadores da saúde, pessoas idosas residentes em instituições de longa permanência (institucionalizadas); pessoas a partir de 18 anos de idade com deficiência, residentes em Residências Inclusivas (institucionalizadas); população indígena vivendo em terras indígenas. [Informe Técnico MS]
Todos os trabalhadores da saúde serão contemplados com a vacinação, entretanto a ampliação da cobertura desse público será gradativa, conforme disponibilidade de vacinas. Ressalta-se ainda que as especificidades e particularidades regionais serão discutidas na esfera bipartite (Estado e Município). [Informe Técnico MS]
Com a autorização da ANVISA e revisão de literatura, a Febrasgo recomenda:
- A segurança e eficácia das vacinas não foram avaliadas em gestantes e lactantes, no entanto estudos em animais não demonstraram risco de malformações.
- Para as gestantes e lactantes pertencentes ao grupo de risco, a vacinação poderá ser realizada após avaliação dos riscos e benefícios em decisão compartilhada entre a mulher e seu médico prescritor.
- As gestantes e lactantes devem ser informadas sobre os dados de eficácia e segurança das vacinas conhecidos assim como os dados ainda não disponíveis. A decisão entre o médico e a paciente deve considerar: o nível de potencial contaminação do vírus na comunidade; a potencial eficácia da vacina; o risco e a potencial gravidade da doença materna, incluindo os efeitos no feto e no recém nascido e a segurança da vacina para o binômio materno-fetal.
- O teste de gravidez não deve ser um pré requisito para a administração das vacinas nas mulheres com potencial para engravidar e que se encontram em condições de risco.
- As gestantes e lactantes do grupo de risco que não concordarem em serem vacinadas, devem ser apoiadas em sua decisão e instruídas a manterem medidas de proteção como higiene das mãos, uso de máscaras e distanciamento social.
- Os eventos adversos esperados devem ser monitorados
- As vacinas não são de vírus vivos e têm tecnologia conhecida e usada em outras vacinas que já fazem parte do calendário das gestantes como as vacinas do tétano, coqueluche e influenza.
- Para as mulheres que foram vacinadas inadvertidamente e estavam gestantes no momento da administração da vacina, o profissional deverá tranquilizar a gestante sobre a baixa probabilidade de risco e encaminhar para o acompanhamento pré-natal. A vacinação inadvertida deverá ser notificada no sistema de notificação e-SUS notifica como um “erro de imunização” para fins de controle. [Informe Técnico]
Risco da infecção do SARS-Cov2 na gestação
Alguns trabalhos sugerem que gestantes com COVID-19 sintomáticas, estão sob risco de doença mais grave comparadas com as mulheres não grávidas. [Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Panagiotakopoulos MMWR 2020, Zambrano MMWR 2020]. Embora o risco para doença grave seja baixo em gestantes, alguns dados indicam que uma vez com a COVID-19, existe um risco maior para complicações como uso de ventilação mecânica, suporte ventilatório e morte comparados com mulheres não grávidas com doença sintomática. ,[ Zambrano MMWR 2020]
Assim como na população geral, as gestantes com comorbidades como obesidade e diabetes, apresentam um risco aumentado para complicações da doença. [Ellington MMWR 2020, Panagiotakopoulos MMWR 2020,Knight 2020, Zambrano MMWR 2020]
Também as gestantes da raça negra e as brancas hispânicas apresentaram uma taxa aumentada de infecções e mortes por COVID-19. Essas diferenças refletem os fatores socioeconômicos que incluem o acesso aos cuidados de saúde.[Ellington MMWR 2020, Zambrano MMWR 2020]
Até o momento da publicação dessa recomendação, duas vacinas foram aprovadas pela ANVISA para uso emergencial., entretanto somente temos a disponibilidade de uma que se encontra no país. Com a iminente promessa de chegada de outro produto e futuras submissões de outras formulações, a Febrasgo estará atualizando essas recomendações de maneira contínua, o mais rapidamente possível, para assegurar um guia seguro para uso dos seus associados.
Autores: Comissão Nacional Especializada em Vacinas da Febrasgo
- Ministério da Saúde Campanha Nacional de Vacinação contra Covid 19 Informe Técnico do MS 18 de janeiro de 2021
- Advisory Committee on Immunization Practices. ACIP recommendations. Available at: https://www.cdc.gov/vaccines/acip/recommendations.html. Retrieved December 11, 2020.
- Centers for Disease Control and Prevention. COVID-19 (coronavirus disease): people with certain medical conditions. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Retrieved December 11, 2020.
- Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Zambrano LD, et al. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status – United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep 2020;69:769-75. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6925a1.htm. Retrieved December 11, 2020.
- Ethical issues in pandemic influenza planning concerning pregnant women. Committee Opinion No. 563. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1138-43. Available at: https://journals.lww.com/greenjournal/Fulltext/2013/05000/Committee_Opinion__No__563__Ethical_Issues_in.47.aspx. Retrieved December 11, 2020.
- Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. UK Obstetric Surveillance System SARS-CoV-2 Infection in Pregnancy Collaborative Group. BMJ 2020;369:m2107. Available at: https://www.bmj.com/content/369/bmj.m2107. Retrieved December 11, 2020.
- Panagiotakopoulos L, Myers TR, Gee J, Lipkind HS, Kharbanda EO, Ryan DS, et al. SARS-CoV-2 infection among hospitalized pregnant women: reasons for admission and pregnancy characteristics – eight U.S. health care centers, March 1-May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1355-9. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6938e2.htm. Retrieved December 11, 2020.
Rafaela López Juárez was determined that if she ever had another child, she would try to give birth at home with a trusted midwife, surrounded by family. Her first birth at a hospital had been a traumatic ordeal, and her perspective changed drastically afterward, when she trained to become a professional midwife.
“What women want is a birth experience centered on respect and dignity,” she said. She believes that low-risk births should occur outside hospitals, in homes or in dedicated birth centers, where women can choose how they want to give birth.
In late February, Ms. López and her family were anticipating the arrival of her second child at their home in Xalapa, Mexico, while following the ominous news of the encroaching coronavirus pandemic. She gave birth to Joshua, a healthy baby boy, on Feb. 28, the same day that Mexico confirmed its first case of Covid-19. Ms. López wondered how the pandemic would affect her profession.
Imaginávamos estar a salvo em nossas sociedades hiperprotegidas e não demos ouvidos aos sinais lançados por outros vírus e aos que pediam planos de contingência.
Este ano longo e triste começou com a pior notícia imaginável: um vírus desconhecido com um potencial pandêmico que demorou alguns meses para se tornar evidente no Ocidente. Mas este ano também termina com a melhor notícia possível dada a situação: a chegada das vacinas contra a covid-19. Elas não resolverão o problema de terça até quinta-feira, mas o farão na segunda metade do ano nos países ricos e, esperamos, dentro de alguns anos no mundo em desenvolvimento.
As vacinas são uma ferramenta essencial da medicina e um dos fatores —juntamente com os antibióticos e o saneamento— que fizeram a expectativa média de vida dobrar no século XX nos países ocidentais, de 45 para 90 anos (arredondando um pouco). Mas nunca a ciência havia respondido tão depressa a um vírus emergente. Viajamos do veneno ao antídoto em apenas um ano. Um feito sem precedentes que exige reflexão. Os historiadores da ciência terão tempo mais adiante para analisar o assunto em detalhes, mas há algumas explicações que podemos traçar agora, quando ainda estamos mergulhados na segunda onda da pandemia e vendo chegar a terceira após as desaconselháveis celebrações natalinas. A primeira é a veloz perspicácia dos cientistas ante a ameaça. Virologistas, epidemiologistas, imunologistas e geneticistas arregaçaram as mangas em janeiro, no mesmo momento em que os cientistas chineses publicaram a sequência genética do SARS-CoV-2, quando ele ainda não tinha esse nome nem nenhum outro (além da designação “vírus chinês” tão apreciada por Donald Trump).
Como fogo na palha, alastrou-se a ideia de que Bill Gates havia previsto a pandemia numa conferência e inclusive apresentado a foto de um coronavírus como ilustração. E é verdade. Mas o motivo pelo qual um dos grandes filantropos de nosso tempo demonstrou tal presciência é que Gates é muito bem informado pela elite científica, que há décadas adverte sobre o risco dos vírus emergentes com potencial pandêmico. E o slide do coronavírus é explicado porque os vírus dessa família, como o SARS e o MERS, já tinham ameaçado o mundo na década passada, como também certas versões do vírus da gripe. Lembram-se? H1N1, H5N1 e toda aquela quantidade de siglas que já parecem arcaicas, mas que continuam por aí esperando sua oportunidade.
Há outras razões para a façanha científica. Num segmento em que o segredo industrial e as patentes costumam dominar o panorama, vimos neste caso uma considerável colaboração entre o setor público e o privado, e também através de fronteiras. Os reguladores auditaram os ensaios clínicos desde o início, e as três fases dos testes foram sobrepostas para acelerar o processo. São lições muito importantes para o futuro. E o mais essencial de tudo é que Governos devem investir intensamente em ciência e medicina. Se isso ocorrer, 2020 terá sido um ano bom apesar de tudo.
Pregnant women around the world have endured inadequate treatment since the start of the pandemic.
It has been one of the shadow, global stories of the pandemic: as countries moved to control Covid-19, maternity services were upended by restrictions. Only this month in the UK it was reported that a woman who was rushed to hospital due to complications following birth was not allowed to see her six-week-old son for six days because of the risk of coronavirus.
The disruption has varied from country to country and throughout the period, but it has been documented globally. Earlier this year, the UN Office of the High Commissioner issued an open call for reports on “women and girls’ sexual and reproductive health in situations of crisis”. In its submission, the Global Respectful Maternity Care Council (the Global RMC Council), which represents 150 organisations in 45 countries, stated: “Since the beginning of the pandemic women have reported a comprehensive suspension of reproductive health services worldwide, particularly in low- and middle-income countries.” This resulted from governments redirecting resources to Covid-19.
The submission continued: “As services were suspended in the early days of the pandemic, women also saw their rights denied and in the name of preventing Covid-19 transmission without sufficient evidence nor justification that these rights violations were necessary or proportionate.”
The Global RMC Council cited examples such as birth companions being banned during labour and delivery, separation of women from newborns if they had Covid-19 or were suspected to have it, and women being “prevented from or discouraged from breastfeeding their newborns” despite a lack of evidence that the virus can be transmitted via breastmilk. It also noted there had been “forced medical interventions, caesarean sections and inductions under the misguided assumption that interventions would accelerate labour and delivery, and minimise viral exposure for women and health providers, and free up hospital beds more quickly despite overwhelming evidence to the contrary”.
An editorial on Covid’s effects in a number of European countries, published in September in the journal Midwifery, reported an increase in virtual antenatal appointments, limits to companionship in labour and at antenatal scans, and some suspensions in the UK of homebirth and birth centre services.
In one extreme example, Midwifery reported that regions in Italy with the highest Covid-19 levels had at times stopped women’s access to epidurals for pain relief during labour because anaesthetists were redeployed to treat coronavirus patients. In Spain, in the early days of the pandemic, some hospitals isolated women with Covid-19 from their babies, with no skin-to-skin contact or breastfeeding allowed, until the mother tested negative. Restrictions have also been reported in the US. One study, published in May in Medical Anthropology, found that “partners and doulas [were] being excluded from birthing rooms” in the early months of Covid-19. The UK has also seen partner visits severely limited on post-natal wards.
A number of campaigns and surveys in the UK have highlighted the mental toll such disruptions have taken on pregnant women and their families. Experts have pointed out that factors such as a woman’s choice of birth partner are not a luxury. As the Global RMC Council put it, there is “tremendous evidence that birth companions improve the likelihood of safe childbirth”.
Throughout the pandemic, the World Health Organisation (WHO) has maintained that Covid restrictions should not undermine a woman’s right to a “positive” experience of birth and “respectful care”, Dr Anshu Banerjee, the director of the WHO’s Department of Maternal, Newborn, Child and Adolescent Health and Ageing, told me.
“We have had concerns that because of the issue of infection prevention and control that maybe some of these positive elements might be undermined,” said Banerjee. “We should make sure that services are provided in a safe manner, but that it still allows that positive experience and thereby also allowing to breastfeed and to have the companion there.”
WHO guidance most recently updated in September – six months after lockdowns or other national restrictions started in most countries – is clear that even if a woman has coronavirus, she should be able to hold and breastfeed her newborn, and have “a companion of choice present during delivery”. The guidance also states that women with Covid-19, or suspected to have it, do not need to give birth by C-section. “WHO advice is that caesarean sections should only be performed when medically justified. The mode of birth should be individualised and based on a woman’s preferences alongside obstetric indications,” it says.
In September the organisation reiterated that it “strongly recommends that all pregnant women, including those with suspected, probable or confirmed Covid-19, have access to a companion of choice during labour and childbirth,” citing its clinical guidelines of management of coronavirus.
“Again and again, research shows that women greatly value and benefit from the presence of someone they trust during labour and childbirth… The benefits of labour companionship can also include shorter length of time in labour, decreased caesarean section and more positive health indicators for babies in the first five minutes after birth,” according to the WHO.
The WHO doesn’t have “systemic data on specific restrictions”, says Dr Ӧzge Tunçalp, of the organisation’s Department of Sexual and Reproductive Health and Research, but it has been “running pulse surveys trying to gauge disruptions”. The WHO has “anecdotal reports and news from different countries across the world, both high-income and low- and middle-income, regarding restrictions on maternity services such as not allowing companions [and] separation of mother and the baby. This also extends to use of unnecessary C-sections.”
An investigation by OpenDemocracy documented violations of the WHO’s guidance in 45 countries, including examples of women in Latin America being pushed to have C-sections because of Covid-19 and the pressure on health services. Early in the pandemic, research on pregnant women in Wuhan found high C-section rates, though they were high in China before the pandemic. One researcher told me that there have been similar reports from countries in Eastern Europe.
There is already some evidence as to the effects of these disruptions. A study published in the Lancet in August looked at birth outcomes and care in childbirth during Nepal’s national lockdown, drawing on data across nine hospitals from January (around 12 weeks before lockdown started in March) to May. The study found that, while births in healthcare facilities decreased by 52.4 per cent during lockdown, the stillbirth rates at hospitals and birthing centres went up from 14 per 1,000 pre-lockdown to 21. Neonatal mortality increased from 13 per 1,000 births to 40.
The researchers found decreases in foetal heart rate monitoring during labour, in rates of breastfeeding within one hour of birth, and in women being accompanied in childbirth. There were some improvements in hand hygiene and “keeping the baby skin-to-skin with their mother”, but the paper concluded that “during the Covid-19 pandemic, women and their babies (both in utero and neonates) are susceptible and at risk due to gaps in care that can result in adverse birth outcomes including mortality. The decrease in the number of institutional births and increase in adverse outcomes are especially concerning because of Nepal’s fragile health system and raise questions on policies regarding strict lockdowns in low-income and middle-income countries.”
The results from Nepal mean that “most likely people came [to seek maternity care] late… because they were afraid of Covid or potentially being infected with Covid at the hospital, so they presented… late and then the outcomes have worsened”, said Banerjee, adding that the same was documented in Sierra Leone during the Ebola outbreak.
The WHO has also been concerned about rates of anxiety and depression among pregnant women and those who have given birth in the pandemic, Banerjee noted. Recent research in the UK found a spike in anxiety and depression among new mothers.
More evidence of the impact disrupted maternity services have had in high-income countries is emerging, too. A nationwide study in Australia, where there are around 300,000 births a year, has been tracking the effects of the pandemic on pregnant women and those who have had children since the coronavirus outbreak began. The researchers have surveyed more than 5,200 such women, and will be continuing the research through follow-up polls.
The study, which will be replicated in New Zealand, was modelled on research following flooding in Queensland in 2010-11, when thousands were evacuated from their homes and dozens were killed, explained Hannah Dahlen, a professor at Western Sydney University’s School of Nursing and Midwifery. The Queensland study looked at the effect of the disaster on women who had been pregnant, as well as on their children’s development in following years. The researchers behind it worked with Dahlen on the “Birth in the Time of Covid-19” study.
Similarly to the UK, in Australia there was a reduction of face-to-face antenatal care in favour of virtual appointments during the pandemic, as well as limits on women being accompanied during labour and at antenatal appointments. Services including water births and birth centres were restricted. Also, as in the UK, Covid-19 restrictions varied from hospital to hospital, sometimes even between those in close proximity, said Dahlen.
When we spoke last month, the Birth in the Time of Covid-19 research had already uncovered some worrying findings. While 16 per cent of respondents said they had considered a previous birth traumatic, 22 per cent of respondents who gave birth during the pandemic said the birth was traumatic, a significant increase. Prevalence of anxiety and depression was also high, said Dahlen.
Continuity of care – being in contact with the same midwife or obstetrician throughout the pandemic – meant respondents “felt buffered from the stress”. This was similar to a finding in the Queensland flood study, where “not only did women have better outcomes but also more babies had better outcomes”, Dahlen said. Some 77 per cent of respondents had experienced tele-medicine, but “it was generally not viewed positively”, she noted. Interactions over the phone were more transactional, and respondents missed the “chit chat” with healthcare providers, which “is powerful social stuff”.
But regarding the overall experience of pregnancy and birth during the pandemic, Dahlen and her colleagues were surprised that around 35 per cent of respondents responded positively. “The positive has been their partner was home, if they are in a happy relationship where they don’t have domestic violence and they have not financially been… really stressed over this event, like losing a job. They felt they fell in love more with their partners, they felt their partners got more engaged with the childcare, and they felt the partner was more attached to the baby because they’ve been there more they may have been.”
There were “still more women who see this [experience] as very negative”, however. Women with mental health issues have had a “particularly bad time”. Respondents reported anxiety about going out with their baby, “about being a bad mother and not giving this baby the same experience as the last”.Birth, Dahlen pointed out, “is the only thing that happens in a hospital that is about being well and doing something that is a normal physiological life event”. It is medicalised, she said, but “having a baby is a deeply psychological, social, culture and spiritual event, and by only viewing it as a physical event we are potentially creating enormous trauma for women and their partners who are bringing babies into the world… and yet it’s caught in the same kind of mentality and restrictions as sick people encounter”. During the pandemic, things that matter to pregnant women and their families, such as choices over pain relief or where to give birth or the presence of partners, have been treated “like a fancy extra rather than a fundamental choice of a woman”.
Lockdowns and measures to control Covid-19 are likely to continue for the time being. In the UK, women are still reporting restrictions in maternity and neo-natal services. The NHS issued new guidance this week stating that partners are “a key component of safe and personalised maternity care”. The Covid-19 vaccine offers hope for a return to normal services in the future. “Once countries have introduced immunisation I think polices will slowly normalise again,” said Banerjee.
But he warned that, “in particular for countries with low health workforce density, repurposing of healthcare workers to plan for and implement the roll-out of the vaccine might lead to reduced services. This is hypothetical but needs to kept in mind in planning the vaccine roll-out.”
Covid-19 has put health services under enormous strain globally. It is striking, however, that not only were maternity services impacted in similar ways worldwide, but that a woman’s right to choose, hard fought for over decades within those services, was impacted in such a similar way. Earlier this year, Dahlen co-authored a paper arguing that the pandemic “exposed an underlying pandemic of neglect affecting women’s reproductive rights, particularly in the provision of abortion services and maternity care”.
“Underlying biases and agendas” have become clear, she told me. “In Australia [restrictions allow us] to half fill football stadiums and have 100 people gamble, but a woman could not have both her doula and her partner support her during her labour. Covid-19 has exposed the patriarchy in ways that were slightly hidden before.” Childbirth choices are a human right and, despite progress, there is still a lot to fight for.
This has implications for the achievement of the UN’s Sustainable Development Goals on maternal and newborn mortality, but it is also a more general warning for the future. As one paper on the US experience in the early days of the pandemic notes, Covid-19 – much like flooding, climate crisis-induced storms and other natural disasters – has seriously impacted maternity care provision. We must learn lessons from this crisis before we face such challenges again.
Mães relatam que, em casa, filhos sofrem com gagueira, depressão, intoxicações e até auto-agressões
Aos 5 anos, o filho de uma arquiteta tem falta de ar e fica dentro de casa andando em círculos e com mania de arrumação. Uma pergunta feita pelo menino a deixa desolada: mamãe, porque você pode sair de casa e eu não?
Voltar a urinar na cama acompanhada por uma repentina gagueira foram os efeitos colaterais que a falta de aulas presenciais e o isolamento social provocou em um menino de 4 anos, filho de uma advogada. A criança agora faz acompanhamento no psicólogo e fonoaudiólogo.
Juliana Sartorelo é médica e mãe de 3 crianças. Ela diz presenciar os reflexos que a falta da escola causa nos alunos de duas formas: no atendimento médico e em casa. Seu filho do meio, de 4 anos, desenvolveu distúrbio do sono e crise de ansiedade. A filha mais velha, de 5, passou o dia inteiro na cama chorando quando uma liminar ordenou que as escolas da capital não retomassem as aulas. E os casos que ela tem atendido no Centro de Toxicologia do Hospital João XXIII são ainda mais graves.
“Percebemos desde o início (da pandemia) que as crianças e adolescentes vêm chegando ao ambulatório com idade cada vez mais jovem. Elas acabam sendo vítimas de privação de alimento e agressão física. Temos visto um crescente número de autoagressão nessas crianças, algumas delas vindas de famílias disfuncionais, com pais dependentes químicos, e outras que ficam a mercê das telas de celulares, pois os pais trabalham fora ou ficam em home office”, contextualiza.
A médica também informa que a falta de aula presencial nas escolas tem criado um outro fenômeno: crianças maiores cuidando de irmãos menores, o que eventualmente acaba resultando em acidentes domésticos. “Teve uma menina de 11 anos que cuidava de uma de 3 e outra de 5. Elas fizeram ingestão de analgésicos e medicamentos de pressão dos pais quando eles saíram para trabalhar. Há casos de crianças que bebem produtos de limpeza, sofrem quedas e outros acidentes por causa da ausência dos pais. Então a escola acaba sendo um refúgio para a criança, seja alimentar ou no contexto de famílias disfuncionais. Sem isso a criança fica muito vulnerável”, argumenta Juliana.
A indignação, segundo as mães, reside no fato de a prefeitura ter proibido a retomada das aulas presenciais sem ter apresentado nenhuma outra alternativa. “O meu filho é invisível para o poder público”, reclama a advogada Luciana Dadalto, mãe do garoto que desenvolveu gagueira. Para ela, falta uma compreensão sobre a defasagem que a falta de aulas presenciais vai causar nas crianças. “Estamos maltratando o futuro. Minha revolta é em relação a isso. O direito à educação é algo constitucional”, alega.
Outra preocupação é que a sociedade entenda que a luta pela retomada das aulas presenciais pode ser feita com cautela e regras sanitárias severas. “Claro que na escola há risco de contaminação, mas há também no boteco, no parque, na praça”, compara a Juliana Duarte, cujo filho começou a ter falta de ar assim que as aulas foram paralisadas.
As mães se intrigam sobre o porquê as aulas em Belo Horizonte continuarem proibidas, sendo que países da Europa, em plena segunda onda da Covid-19, priorizaram o funcionamento das escolas, segundo elas. “A escola não pode ser esse lugar da Covid. Se abrem clubes e cinemas e meu filho pode ir a esses lugares, estamos pedindo é uma explicação”, diz a arquiteta.
Elas também sentem que os filhos estão com comportamentos de sociabilidade alterados. “São crianças que estão na fase de formação de caráter, o que é feito através do contato físico. A criança fora da escola não se esforça em fazer parte de grupo nenhum. Dentro da escola ela aprende a aceitar o não e os limites do outro”, responde Juliana.
“Naturalizamos crianças sozinhas em casa”, afirma escola
Não são apenas mães e pais que têm sentido as dificuldades que a falta de aulas presenciais manifestam nas crianças. Nas escolas, o reflexo também é percebido e alimenta preocupações entre equipes pedagógicas. Para Letícia Fonseca, uma das proprietárias da escola particular Clic, no bairro São Pedro, região Centro-Sul da capital, a educação está sendo colocada de escanteio e o prejuízo não está sendo devidamente calculado.
“Naturalizamos que as crianças podem ficar sozinhas em casa vendo televisão. A janela de aprendizagem vai passar, e como vamos recuperar isso depois?, questiona. “A escola é o maior centro de convivência para as crianças, ajuda a construir conceitos éticos, morais, de autoconhecimento e diversidade. Atua na formação da personalidade e identidade. Não podemos deixar isso para amanhã”, desabafa.
Escolas sem data para reabrir
O Sindicato das Escolas Particulares de Minas Gerais (Sinep-MG) informou que recebe diversos relatos de crises emocionais dos estudantes, estresse, depressão, dentre outras questões que envolvem a saúde mental. Para o sindicato, as estratégias dos órgãos públicos de combate à pandemia no ramo educacional são generalistas.
“O retorno às atividades poderia ser opcional e controlado”, diz a nota enviada pela entidade. O Sinep afirma ainda que “o poder público atrasa o retorno presencial às atividades escolares por interesses políticos e por não oferecer condições às escolas municipais e estaduais de se adaptarem a este momento”.
Consultada, a prefeitura de Belo Horizonte informou que ainda não é possível reabrir as escolas para aulas presenciais. Segundo o Executivo, a previsão é que a abertura aconteça quando a incidência média por 100.000 habitantes atinja valores compatíveis com baixo risco (menor do que 20 novos casos por dia) para a saúde pública.
Sobre demandas de saúde mental apresentadas por alunos, a prefeitura relatou que os centros de saúde contam equipes de saúde mental formadas por psicólogos e psiquiatras. Eles atuam no acompanhamento ambulatorial também de crianças e adolescentes. A Unidade de Acolhimento Infantil e os Centros de Referência em Saúde Mental Infantojuvenil completam a rede de atendimento. O número de atendimentos foi de 104.061 (2019) e 53.976 (até 30 de outubro de 2020).
Questionada sobre quais propostas alternativas foram pensadas para a educação durante a pandemia, a administração municipal informou que implementou o regime especial de atividades escolares, estratégia que alcança a educação infantil, ensino fundamental e alunos do Educação de Jovens e Adultos (EJA). As atividades são asseguradas por meios físicos impressos ou eletrônicos.
But what if they are pregnant?
Like all pregnant women, health care workers will be operating without much data, as pregnant women have been excluded from clinical trials so far.
Pregnant women are commonly excluded from research, something that has frustrated Dr. Emily Miller for years. Miller is the assistant professor in the Division of Maternal-Fetal Medicine at Northwestern Medicine’s Feinberg School of Medicine, where she has been closely following the lack of data on pregnant women and new vaccines.
“As it turns out, pregnant women can be doctors and nurses and respiratory therapists,” she said. “This is putting our pregnant health care workers in a place where they haven’t been given a lot of concrete guidance because they’ve been systematically excluded.”
This essentially results in “clinical experimentation on pregnant women, as vaccines are distributed and administered without the safeguards of research in place,” according to a Society for Maternal-Fetal Medicine statement released Tuesday. Miller is a member of the task force.
In a conference call on vaccine progress Thursday morning with the Infectious Diseases Society of America, Dr. Kathleen Neuzil, co-director of the National Institutes of Health’s COVID-19 Prevention Network, acknowledged pregnant women should be included in vaccine research.
“We know that women of childbearing age make up a large proportion of health care workers, make up a large proportion of front-line responders,” she said. “So we really don’t have a vaccine for everyone, until we have a vaccine for pregnant women.”
The Society for Maternal-Fetal Medicine statement recommended that health care workers be offered the vaccine if pregnant.
In general, for pregnant women, the group recommended access to COVID-19 vaccines in all phases of future vaccine campaigns.
The statement noted that with mRNA vaccines, likely to be the first available and which induce an immune response, the theoretical risk of fetal harm is very low.
Miller acknowledged that people have “lingering questions” about COVID-19 and the new vaccines.
“It has to be balanced against the risk of not getting the vaccine, which is the risk of acquisition of (COVID-19), which has concrete and well-documented risks,” she said. “Through that lens, if we can remember that there is no zero-risk option, then the balance at this point favors receiving the vaccine.”
The society criticized the lack of available data and noted that if multiple vaccines become available, “some vaccines may be more suitable for pregnant women.”
As much as the limited data frustrates Miller, she emphasized that what is known is that if women are pregnant, or become pregnant, and contract COVID-19, they are at risk of getting very sick.
“That’s super worrisome,” she said.
Women considering becoming pregnant will similarly have no available information on pregnancy after getting the vaccine.
Dr. Ann Borders, an OB-GYN and executive director of the Illinois Perinatal Quality Collaborative, said she expects vaccination will be recommended for women considering pregnancy, as they are entering a high-risk category. Borders plans to bring up the topic on a call this Friday with the collaborative.
Lactating women also have been left out of clinical trials, even though, as the Society for Maternal-Fetal Medicine’s statement noted, “there is no biological plausibility for the exclusion of lactating women.”
Miller said this highlights that women deserve more information.
“We need to be shifting our mindset from this mantra of we need to protect pregnant women from participating in trials, and instead shift it to we need to protect pregnant women from being excluded from these trials,” she said.
Miller said she will be watching closely to see if the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices offers any pregnancy-specific guidance. She also expects that, out of the many people involved in trials, some will become pregnant after taking the vaccine.
Patients should discuss options with their OB-GYNs.
“There isn’t a simple answer to questions about whether pregnant people, or those considering pregnancy, should take the COVID-19 vaccine, especially since no vaccine is currently approved,” Christopher Zahn, the vice president of practice activities of the American College of Obstetricians and Gynecologists, said in a statement. “When the vaccines do become widely available, unfortunately, we have no data on the safety of the vaccine in pregnant and lactating individuals because they were excluded.”
Zahn said patients should consider any available data, patients’ individual risk factors and their “unique needs, desires and values.”
The CDC’s general guidelines for vaccinating pregnant women, which were last updated in 2016, notes that the benefits, in general, “usually outweigh potential risks when the likelihood of disease exposure is high.”
Already, OB-GYNs strongly encourage, for example, a flu vaccine, as pregnant women are similarly more prone to getting sicker from the flu, because of changes in the immune system, heart and lungs during pregnancy.
The Illinois Department of Public Health has long emphasized the importance of health care providers’ advice to pregnant women, noting that women who received a recommendation for a flu vaccine and an offer of vaccination were six times more likely to be vaccinated, compared with women who did not receive a recommendation or an offer of vaccination.
Miller hopes women feel empowered by discussing this issue with their provider.
“Getting COVID-19 in pregnancy is incredibly serious,” she said. “Let’s empower you to do everything, to use every tool in the toolbox to stay safe.”