Pregnancy-associated deaths will increase in the COVID-19 era

Maternal mortality due to partner violence, suicide, and substance overdoses will increase due to COVID-19.

Do blog da Maternal Health Task Force

 

By: Kathryn Mishkin, DrPH, MPH, MA, Associate Director of Evaluation, March of Dimes; Rahul Gupta, MD, MPH, MBA, FACP, Chief Medical & Health Officer, SVP, March of Dimes; Roland Estrella, MS, MBA, Senior Director of Science, Data, and Evaluation, March of Dimes

 

COVID-19 has devastated the lives of the American people with over 250,000 deaths to date, and this impact is going to extend to pregnant and postpartum women.

This is terrifying considering that the United States entered the pandemic with the infamous status of having the highest maternal mortality rate among all developed nations. Already, researchers are concerned about an increase in maternal morbidity and mortality due to COVID-19’s effect on pregnant women’s immune systems, its contribution to cardiopulmonary complications, and the higher rates of hospitalizations and ICU visits among pregnant women with COVID. It is feared that Black women will be particularly affected, and this is troubling considering that Black women were already four times more likely to die in the maternal period compared to White women pre-COVID.

It is clear that COVID-19 will adversely affect pregnant and postpartum women’s physical health.

However, current predictions have not yet painted a full picture of how COVID-19 may contribute to an increase in maternal mortality in the United States. It is essential that we expand our discussion beyond medical causes of death to include maternal deaths due to suicide, substance overdose, and homicide as a result of partner violence.

We expect pregnant and postpartum women to die more frequently from these causes because we are seeing this happen in the general population. Since January, drug overdoses have spiked according to the Office of National Drug Control Policy. A physician in California says he has seen more deaths from suicide than COVID-19, with a year’s worth of suicide deaths occurring in just four weeks. The United Nations Population Fund predicts IPV rates will increase by 20% during a three-month quarantine. Physical distancing, while protective against COVID-19, exacerbates the risk of being abused and suffering from mental illness because of social isolation and increased stress. From a social perspective, women are now facing the brunt of increased responsibility for domestic responsibilities that comes with the “new normal”, and this added stress will have an impact on their health.

Furthermore, we know that pregnant and postpartum women were dying from these causes before the pandemic. A global study revealed that 13-36% of maternal deaths are due to suicide. In 2016, Philadelphia’s maternal mortality review reported that nearly half of pregnancy-associated deaths were due to injuries including homicide, suicide, and drug overdoses. In California, research shows that drug-related and suicide deaths are the second and seventh leading cause of maternal deaths, respectively, constituting 18% of all maternal deaths.

We also know that certain populations are at higher risk for these types of deaths. People living with underlying mental illness are at higher risk for dying from suicide and substance overdose deaths and women experiencing IPV are more likely to have a mental illness. Measures taken to limit the spread of the virus will result in reduced access to and use of care and support for some at-risk populations.

In sum, pregnant and postpartum women were already experiencing IPV, suffering from mental illness, and using substances, and COVID-19 will exacerbate these issues.

We call on public health leaders to join the #Blanket Change movement to raise awareness about the urgent health crisis moms and babies are facing in order to ramp up prevention and care and support documentation of these deaths.

Prevention of death due to these causes is possible but requires an effective and efficient health care and social support system. The American College of Obstetricians and Gynecologists provides recommendations for screening for substance use, IPV, and depression. In spite of this, screening appears to be lacking. For example, a recent report by the Centers for Disease Control and Prevention stated that 20% of women were not asked by their health care provider about depression symptoms in the prenatal period and 12.5% were not asked in the postpartum period, with a wide discrepancy in rates depending on where a woman was living.  We call on health care providers to improve screening for mental illness, IPV, and substance use to improve the health of moms and babies.

In addition to effective prevention, we call for all states to document the frequency of deaths due to suicide, IPV, and substance overdose through maternal mortality review.  Full documentation on a national scale will allow us to develop a better understanding of the reasons that pregnant and postpartum women are dying. Without a comprehensive review, our ability to develop critical recommendations to prevent future deaths will remain inadequate.

LONG-COVID IN CHILDREN – PARENTS AND FAMILIES’ PERSPECTIVES NEED TO BE HEARD

Long-COVID in Children – Parents and families’ perspectives need to be heard

Frances Simpson is a founding member of LongCovidKids and LongCovidSOS and a Lecturer in Psychology at Coventry University. She is on Twitter: @FrancesorFran

Carolyn Chew-Graham is a GP in Central Manchester and Professor of General Practice Research at Keele University; Carolyn’s main areas of interest include the primary care management of people with multiple health conditions and difficult to understand symptoms which are key components of her clinical work. She is on Twitter: @CizCG

Amali Lokugamage is a consultant in obstetrics and gynaecology, and honorary associate professor and currently has long covid. She is on Twitter: @Docamali

PARENTS HAVE BEEN STRUGGLING to obtain help and support, watching their children with persistent symptoms following acute infection with COVID-19. Early on in the pandemic, parents and children felt they were disbelieved by their general practitioners (GPs) as they witnessed an emerging phenomenon. As ‘Long-COVID’ came to be recognised in adults1 and named as such by patients2 there came to be a growing acceptance that Long-COVID can also occur in children as evidence emerged.3 Indeed, ONS statistics suggest that 12-15% of children may have symptoms lasting 5 weeks after an acute infection with COVID-19.

12-15% of children may have symptoms lasting 5 weeks after an acute infection with COVID-19.

The lack of GP awareness has led to some parents whose children have long-COVID feeling that their children’s symptoms were minimised or even ‘gaslighted’; experiences that were highlighted in the recent All Party Parliamentary Group (APPG) about Long Covid in children on 26th January 2021. Parents described desperation and fear of seeking further help, not wanting to be branded with the stigma of ‘Munchausen by proxy’. While the adult population of Long-COVID sufferers were assembling on social media groups and collecting data, children were discounted under the misconception that children did not get COVID severely, that they did not transmit COVID, that they were often asymptomatic.4 Even when the facts of paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) in children started to present themselves,5 it was understood that this was very rare. When parents started to wonder why their children were becoming ill from COVID and not making a full recovery, there was no narrative in existence that helped them to make sense of this.

Parents described desperation and fear of seeking further help.

Through desperation, mothers Frances Simpson and Sammie McFarland, whose children became sick in March 2020, joined forces to start the support group LongCovidKids. These families found themselves in a confusing place of being told that there was no proof that their childrens’ symptoms were a result of COVID, due to the lack of testing available in Spring 2020. LongCovidKids has evolved to provide support for families with Long-COVID; this now has 940 parents or carers, many of whom have more than one child with Long-COVID. Symptoms described by members of the group range from the most common symptoms of fatigue, headache, abdominal pain, dizziness and muscle pain to the most frightening to parent – electric shock-like pain in the eyes and head, nerve pain, testicular pain, liver damage, paralysis and new-onset seizures; some of their experiences are captured in a film.

Parents have noted that their children are also affected by anxiety, OCD and extremely volatile mood changes which may be associated with neuro-inflammatory processes6 as well as a natural response to being so unwell. The majority of parents would describe their child’s symptoms as fluctuating, and many describe a gap of many weeks between the acute stage and the start of Long-COVID. This variability causes further confusion when presenting the problems to a GP and often leads to diagnoses of anxiety or symptoms attributed to the effects of lockdown or home-schooling.

Children are also affected by anxiety, OCD and extremely volatile mood changes which may be associated with neuro-inflammatory processes.

The combination of an often mild or asymptomatic acute illness, followed by delayed debilitating symptoms of Long-COVID, lack of testing and limited awareness amongst GPs about the syndrome has meant that in the UK it is currently difficult to assess the prevalence of Long-COVID in children. The ONS data has now given us some estimation and the recent European data helps to validate this emerging condition in children.3

NHS England now recognises that Long COVID in children needs urgent evaluation and as this official recognition, epidemiological evidence and long-COVID paediatric services evolve, it is hoped that GPs will be provided the resources they need to support families where children are affected by Long-COVID.

In consultations with parents and children, it is preferable to admit to the limitations of knowledge, whilst being interested in the experiences of the family, believing in presented problems and offering support, help and referral. Parents who are frightened for their child need to feel listened to, and the child needs their experiences to be validated. After all, their lived experiences are also valuable evidence.

 

References

  1. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ2020;370:m3026. doi:10.1136/bmj.m3026 pmid:32784198
  2. Body Politic COVID-19 Support Group. Report: what does covid-19 recovery actually look like? 2020. https://patientresearchcovid19.com/research/report-1/
  3. Buonsenso D, Munblit D, De Rose C et al; Preliminary Evidence on Long COVID in children. medRxiv 2021.01.23.21250375; doi: https://doi.org/10.1101/2021.01.23.21250375
  4. Zimmermann P, Curtis N. Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infectionsArchives of Disease in Childhood Published Online First: 01 December 2020. doi: 10.1136/archdischild-2020-320338
  5. Harwood R, Allin B, Jones CE et al; PIMS-TS National Consensus Management Study Group. A national consensus management pathway for paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS): results of a national Delphi process. Lancet Child Adolesc Health. 2021 Feb;5(2):133-141. doi: 10.1016/S2352-4642(20)30304-7. Epub 2020 Sep 18. Erratum in: Lancet Child Adolesc Health. 2021 Feb;5(2):e5. PMID: 32956615; PMCID: PMC7500943.
  6. Mazza MG, De Lorenzo R, Conte C et al; COVID-19 BioB Outpatient Clinic Study group, Benedetti F. Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors. Brain Behav Immun. 2020 Oct;89:594-600. doi: 10.1016/j.bbi.2020.07.037. Epub 2020 Jul 30. PMID: 32738287; PMCID: PMC7390748.

 

Featured photo by Kat J on Unsplash

A history of the medical mask and the rise of throwaway culture


Published: May 22, 2020 – The Lancet
DOI: https://doi.org/10.1016/S0140-6736(20)31207-1
The shortage of face masks during the COVID-19 pandemic has become a symbol of the fragility of modern medicine and public health. Several explanations have been advanced for this situation, from a panicking public hoarding masks to the offshoring of manufacturing and the disruption of global trade. The history of medicine suggests another factor could be considered: the progressive replacement of reusable face masks by disposable ones since the 1960s. Medicine has been transformed by consumer culture—what Life Magazine enthusiastically named “Throwaway Living” in 1955. The history of the medical mask illuminates how this vulnerability was created.
Covering the nose and mouth had been part of traditional sanitary practices against contagious diseases in early modern Europe. This protection was primarily about neutralising so-called miasma in the air through perfumes and spices held under a mask, such as the plague doctors’ bird-like masks. Such practices, however, had become marginal by the 18th century. Face masks, as they are used today in health care and in the community, can be largely traced back historically to a more recent period when a new understanding of contagion based on germ theory was applied to surgery.
(…)
Leia a íntegra no The Lancet

Choque hiperinflamatório em crianças durante a pandemia de COVID-19

O South Thames Retrieval Service, em Londres, Reino Unido, fornece apoio e recuperação em terapia intensiva pediátrica a 2 milhões de crianças no sudeste da Inglaterra. Durante um período de 10 dias, em meados de abril de 2020, foi observado um grupo sem precedentes de oito crianças com choque hiperinflamatório, mostrando características semelhantes à doença atípica de Kawasaki, síndrome de choque da doença de Kawasaki, ou síndrome do choque tóxico (o número típico é de uma ou duas crianças por semana). Esse cluster de casos formou a base de um alerta nacional.

Acesse o artigo original no The Lancet

Hyperinflammatory shock in children during COVID-19 pandemic

Published: May 07, 2020  DOI:https://doi.org/10.1016/S0140-6736(20)31094-1

Síndrome inflamatória multissistêmica em crianças e adolescentes associada à COVID-19 (MS)

BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Imunização e Doenças Transmissíveis. Coordenação-Geral do Programa Nacional de Imunizações. SEI/MS – 0014893980 – Anexo. Nota de Alerta: Síndrome inflamatória multissistêmica em crianças e adolescentes associada à COVID-19. 22 Mai.2020.

O Ministério da Saúde, por intermédio do Programa Nacional de Imunizações e da Coordenação de Saúde da Criança e Aleitamento Materno, assim como a Sociedade Brasileira de Pediatria, representada neste documento pelos Departamentos Científicos de Infectologia e Reumatologia, e a Sociedade Brasileira de Reumatologia, bem como a Organização Pan Americana de Saúde, reconhecem a necessidade deste alerta à comunidade pediátrica, reforçando a importância do diagnóstico e tratamento precoces.

Publicado originalmente no Portal de Boas Práticas em Saúde da Mulher, da Criança e do Adolescente do IFF-Fiocruz, acesse o original.

Oedipus and the Coronavirus Pandemic

Oedipus and the Coronavirus Pandemic (acesse o original)

JAMA. Published online May 21, 2020. doi:10.1001/jama.2020.8594

Last week I faced the task of telling brand-new parents that their 2-lb premature son needed emergency surgery. The conversation was all the more difficult because, surgery or no surgery, odds were he would die. They agreed to the procedure with one request: that we allow his grandparents and uncles the chance to meet him first. They didn’t want their son to die alone.

Ordinarily, I could facilitate such a reasonable request. Even in normal times, the hospital isolates patients from home, family, and community, so this seemed like a small sliver of grace. Yet even this was now precluded; in response to the ongoing pandemic, our hospital has instituted a necessarily stringent visitor policy.

The most inflexible policies are reserved for the COVID-19 unit, which only allows one parent, clothed in gown, gloves, mask, and goggles, to stay per sick child. This parent cannot leave the hospital room until the child is discharged. Knowing they too will likely get infected, parents choose to enter in so their child does not suffer alone.

The isolation we have experienced during the current pandemic has refocused our attention on the tendency of modern medicine to isolate individual patients. There lies a strict barrier, for example, between my operating room and the world outside. Only a select few are permitted to enter. And patients are often left alone in our ICUs, lulled by the rumbling of machines while in a semiconscious state. Pandemic-era policies have simply intensified the isolation that has already established itself as routine in medicine: we isolate the sick to make them well.

To be sure, in our current moment, the isolation and physical distancing so many endure are an acute necessity. But these severe measures should impassion us to lessen the isolation of those we care for once the pandemic is behind us. As we look forward, can we reimagine communal health, the practice of medicine, and the more subtle ways our systems and procedures might change?

Before the current pandemic, poet-farmer and cultural critic Wendell Berry reflected on the isolating effects of medicine in the wake of his brother’s massive heart attack. John, Berry’s brother, required emergency surgery and lengthy intensive care, which necessarily removed him from his daily life and community. During his hospitalization, Berry recalls, “the world of specialization, machinery, and abstract procedure” seemed incompatible with the world John came from—the world of love—embodied in the family, friends, and neighbors who gathered at his bedside. This community attempted to preserve John’s connection to the outside world and more importantly, to his humanity. Despite medicine’s seemingly necessary focus on the individual patient, Berry claims that community is “the smallest unit of health and that to speak of the health of an isolated individual is a contradiction in terms.”1

Our current scenario and the isolation it requires contains haunting echoes of Oedipus’ Thebes when it was ravaged by plague. In the opening scene of the classic Greek tragedy Oedipus Rex, the contagion’s effects are evident as the streets lie empty, children are ripped from their parents, and citizens from their polis. A priest laments:

A blight is on the fruitful plants of the earth,
a blight is on the cattle in the fields,
a blight is on our women that no children
are born to them; a god that carries fire,
a deadly pestilence, is on our town,
strikes us and spares not, and the house of Cadmus
is emptied of its people while black Death
grows rich in groaning and in lamentation.”2
Eugene-Ernest Hillemacher (1818-1887), Oedipus and Antigone Exiled From Thebes, circa 1843, French. Oil on canvas.
Eugene-Ernest Hillemacher (1818-1887), Oedipus and Antigone Exiled From Thebes, circa 1843, French. Oil on canvas. Musée des Beaux-Arts, Orleans, France. Bridgeman Images.

As the play continues, we learn that the pestilence is divine retribution for the murder of the late King Laius and that only by finding and banishing the one guilty of his murder will Thebes be saved from calamity. So the city turns to its new king Oedipus, a wise leader beloved by all who was crowned after his wit and intelligence earlier saved Thebes from the deadly Sphinx by solving her riddle.

It is to Oedipus’ (and our) shock and horror that he discovers he killed his father. Apollo’s oracle had prophesied Laius’ murder at Oedipus’ birth. Attempting to defy the prophecy, Laius leaves Oedipus to die on a hillside. The child is rescued and raised in Corinth and, learning of the prophecy when he comes of age, flees. During this flight Oedipus meets Laius at a crossroad and is forced off the path. Enraged, he kills the old man not knowing him to be both his father and king. Oedipus also unknowingly takes his mother Jocasta as his wife—a reward for freeing Thebes from the Sphinx. The climax of the tragedy is Oedipus’ recognition of these transgressions, and that his greatest strength—his proverbial sight, his wit and wisdom—are the source of plague on the entire city of Thebes. So humbled, he pierces his eyes that he might not ever deceive himself or harm others again and leaves the city in order to redeem it, sightless and never to return.

The story in Oedipus Rex sheds light on our current reality, accentuating some of the moral problems of modern medicine beyond the question of ventilator rationing.

What the polis finally relies on for its salvation—Oedipus himself, seemingly the greatest of its mortal hopes—is found to be the cause of its own demise. Likewise, medicine, at the same time that it brings much healing, becomes the means of patients’ isolation and intensifies the antimembership of our procedures, inadvertently in normal times, by design during this pandemic.

The plague of Thebes also speaks to the communal nature of suffering. Despite the modern fixation on “individualized medicine,” the current pandemic reveals radical individualism as a facade. We are social animals. A physician in New York recently told me, “The worst part about COVID-19 is that patients die alone, without their families by their sides.” Experts recognize that the isolation experienced by mandated physical distancing is having serious mental health consequences.3

As a genre, tragedy aims to teach citizens how to bear and respond to suffering, how and when it is proper to feel pity and fear. The original Athenian audience watching the play would have recognized that if this could happen to Oedipus, “whom all men call the Great,” the same could happen to them.2 Tragedy instructs us to accept the limits of our existence. The coronavirus is a reminder of our vulnerability and our finitude. Oedipus, despite his wit and intelligence, could not save his family or city from suffering and death. Similarly, medicine, despite its remarkable technological advances, ultimately cannot save us from the same.

Yet even in suffering there is hope. Although Oedipus leaves Thebes, he does not leave alone. Neither does he suffer alone. In Sophocles’ late play Oedipus at Colonus, he is attended by his daughters. No easy task, Antigone and Ismene suffer alongside the old blind man. Because he has not been completely isolated, his suffering can be shared and informed by love. A messenger recounts the deathbed encounter between Oedipus and his daughters:

Then the earth groaned with thunder from the god below;
and as they heard the sound, the girls shuddered
and dropped to their father’s knee, and began wailing,
beating their breasts and weeping, as if heartbroken.
And hearing them cry out so bitterly
he put his arms around them, and said to them:
“Children, this day your father is gone from you.
All that was mine is gone. You shall no longer
bear the burden of taking care of me—
I know it was hard, my children. And yet one word
frees us of all the weight and pain of life:
that word is love.”4

In my job, I feel defeated by death almost daily amidst the seemingly endless buzz of machines and procedures. Yet, as Berry reminds us, “the world of love includes death, suffers it, and triumphs over it…the world of love continues, and of this grief is the proof.”1 Perhaps one way to prevent medicine from becoming the enemy of its own kindred, as Oedipus inadvertently was to Thebes, is to ensure that love, which wills the good of the other, is present—even in a pandemic, even when supplies are short. Medicine is at its finest when it restores individual patients to the world of love. Seen from this perspective, the work of medicine itself can be an act of love.

 

And so I bring my patient back from the operating room to his expectant parents, grandparents, and uncles, back from the world of isolation, machines, and abstraction, into the world of love.

Article Information

Corresponding Author: Ryan M. Antiel, MD, MSME, Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, One Children’s Place, St Louis, MO 63110 ([email protected]).

Published Online: May 21, 2020. doi:10.1001/jama.2020.8594

Conflict of Interest Disclosures: None reported.

References

1.

Berry  W.  Another Turn of the Crank: Essays. Counterpoint; 1995.

2.

Sophocles. Oedipus the King. In: Grene  D, Lattimore  R, Griffith  M, Most  GW, trans, eds.  Sophocles I. 3rd ed. University of Chicago Press; 1991:73-142.

3.

Galea  S, Merchant  RM, Lurie  N.  The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention.   JAMA Intern Med. Published online April 10, 2020. doi:10.1001/jamainternmed.2020.1562
ArticlePubMedGoogle Scholar

4.

Sophocles. Oedipus at Colonus. In: Grene  D, Lattimore  R, Griffith  M, Most  GW, trans, eds.  Sophocles I. 3rd ed. University of Chicago Press; 1991:145-224.

UNA-SUS tem conteúdo dedicado a COVID-19

O Sistema Universidade Aberta do SUS (UNA-SUS) coordenado pelo Ministério da Saúde, por meio da atuação conjunta da Secretaria de Gestão do Trabalho e da Educação na Saúde (SGTES/MS) e da Fundação Oswaldo Cruz (Fiocruz), conta com uma rede colaborativa formada atualmente por 35 instituições de ensino superior que oferecem cursos a distância gratuitamente.

Atualmente o portal reúne artigos dedicados ao coronavírus e a COVID-19.

Veja abaixo parte do conteúdo disponibilizado:

 

Acesse o site da UNA-SUS para consultar todos os artigos.