COVID-19’s impact on maternal and child health

How COVID-19 will impact our lives on maternal and newborn healthcare front in India. If the gains made in the past decade be lost due to pandemic? Role of PREVENT Study

Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, a newly emergent Coronavirus, that was first recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that it is a Beta-Coronavirus closely linked to the SARS virus. By definition, a symptomatic COVID-19 case is a person who has developed signs and symptoms suggestive of COVID-19.

As on 25 June 2020 more than 9 million people have been reported to be infected by the novel coronavirus globally. In India, total cases of coronavirus rose to half a million as per the latest updates, with more than 14,900 have died due to virus [1].

 Effect of COVID-19 on Pregnancy and foetus

Emerging evidence regarding vertical transmission (transmission from mother to baby antenatally or intrapartum) suggests that it is probable, although the proportion of pregnancies affected and the significance to the neonate is yet to be determined. At present, there are no recorded cases of vaginal secretions being tested positive and no recorded cases of breast milk being tested positive for COVID-19 [2].

There is no evidence suggesting that pregnant women are more likely to contract the infection than the general population. However, pregnancy itself alters the body’s immune system and response to viral infections in general, which can occasionally be related to more severe symptoms and this will be the same for COVID-19. Reported cases of COVID-19 pneumonia in pregnancy are mild followed by good recovery. Pregnant women with heart disease are at highest risk for acquiring the infection. The COVID-19 epidemic increases the risk of perinatal anxiety and depression, as well as domestic violence. It is critically important that support for women and families is strengthened as far as possible. There are currently no data suggesting an increased risk of miscarriage or early pregnancy loss in relation to COVID-19. This infection is currently not an indication for Medical Termination of Pregnancy. There is also no evidence that the virus is teratogenic (disturb the development of an embryo or foetus) yet.

While the COVID-19 pandemic has increased rate of mortality in general due to the virus, it has also increased risk of mortality indirectly.  An analysis of the 2014 outbreak of Ebola virus in West Africa showed that the indirect effects of the outbreak were more severe than the outbreak itself. Preparing and responding to COVID-19, a public health emergency, has strained the already over-stretched health system in India causing severe risk disruptions in the provision of health services, particularly for mothers and children.  Although mortality rates for COVID-19 appear to be low in children and in women of reproductive age, these groups might be disproportionately affected by the disruption of routine health services, particularly in low-income and middle-income countries like ours.

WHO commended India in the year 2018 for its ground-breaking progress in recent years in reducing the maternal mortality ratio (MMR) by 77%, from 556 per 100000 live births in 1990 to 130 per 100000 live births in 2016.  India’s present MMR is below the Millennium Development Goal target and puts the country on track to achieve the Sustainable Development Goal target of an MMR below 70 by 2030 [3]. 

In the event of a nationwide lockdown due to COVID, the restriction of physical movement, social distancing, financial resources being directed towards tackling the outbreak, and the fear of contracting the virus negatively impacts the health-seeking behaviour of pregnant women and her family. A recent study on the impact of COVID-19 on the Sexual Reproductive Maternal New-born Child Adolescent Health provision in 132 low- and middle-income countries indicates that a modest decline of 10 percent coverage of pregnancy and new-born health care would have serious implications for the lives of women and their new-borns that could result in additional maternal and new-born deaths [4]. Hence assuring pregnant women have access to safe birth and continuum of antenatal and postnatal care during COVID gains more importance, though it is indeed challenging. Many places in India has suspended the routine outpatient care during the lockdown period of about 10 weeks which affects the maternal health indirectly.

In 2019, as per the Health Management Information System, 3.5 million sterilizations, 5.7 million intra-uterine contraceptive devices (IUCDs), 1.8 million injectable contraceptive services were provided by the public sector. Public health facilities also distributed 41 million cycles of oral contraceptive pills (OCPs), 2.5 million emergency contraceptive pills (ECPs) and 322 million condoms [5]. Due to lockdown the use of contraception has been compromised to a large extent. In line with the Ministry of Health and Family Welfare, Government of India’s advisory, public facilities have suspended provision of sterilizations and IUCDs till further notice. Curbs on movement have made access to over the counter contraceptives, Condoms, OCPs and ECPs difficult.

In the most likely scenario (where clinical family planning services operate at full capacity by September 2020) it is estimated that 25.6 million couples would have not been able to access contraception services during the period of the lockdown directly affecting the maternal health and increasing number of unwanted pregnancies. As COVID-19 continues to spread globally, over 117 million children in 37 countries may miss out on receiving life-saving measles vaccine and other routine vaccination. Measles immunization campaigns in 24 countries have already been delayed; more will be postponed [6]. Despite having a safe and effective vaccine for over 50 years, measles cases surged over recent years and claimed more than 140,000 lives in 2018, mostly of children and babies – all of which were preventable. Against this already dangerous backdrop, preventive and responsive measles vaccination campaigns have now been paused or postponed in 24 countries to help avert further spread of COVID-19. Campaigns which are expected to take place later in 2020 in an additional 13 countries may not be implemented. Together, more than 117 million children in 37 countries, many of whom live in regions with ongoing measles outbreaks, could be impacted by the suspension of scheduled immunization activities. This staggering number does not include the number of infants that may not be vaccinated because of the effect of COVID-19 on routine immunization services. Children younger than 12 months of age are more likely to die from measles complications, and if the circulation of measles virus is not stopped, their risk of exposure to measles will increase daily.

ROLE OF PREVENT TEAM IN MITIGATING THESE CHALLENGES

Helping COVID Warriors: PREVENT study was suspended since beginning of lockdown to reduce the burden of COVID positive cases and to promote social distancing. Once the study commences at different sites, PREVENT team is planning to help all clinical staffs of recruiting centres with basic medical supplies including masks, head gears and sanitizers. Educational sessions will be conducted to all health care workers and hospital staff about hand washing and its importance.

Routine Vaccination: While COVID-19 is disrupting daily routine, parents will be counselled to get child vaccinated at scheduled time. It is important that children and babies keep their vaccinations up to date because they protect them from serious diseases. It means that when children can return to interacting with other children, they will have protection from some other diseases too.

Counselling of Parents: In addition to all of the advice already given to parents about frequent hand washing, social distancing and maintaining personal hygiene practices, they will be counselled to protect infants from infection. Breastfeeding is advised as there is currently no proven research that breastmilk can transmit the virus, but mother should take the usual hygiene and respiratory protection (while breastfeeding as well as at other times) to avoid respiratory transmission. Parents will also be advised to have the same caregivers for other children at home to reduce the number of people they come into contact with. Those caregivers should be encouraged to wash their hands regularly, avoid sharing things that go in mouths such as cups and stay away if they feel at all sick.

If child has a sore throat, cough or fever, parents will be informed to call doctor or health service for advice before bringing them in. They may have a special arrangement at the clinic to minimise spread of infection to others. If the child has more serious symptoms, like shortness of breath or seems unusually sick, parents advised to take child to the nearest emergency department. As with other respiratory infections like the flu, seeking care early is advised. Parents are also advised to avoid going to public places, and not to be in contact with the elderly or immunocompromised family members.

This crisis proves one thing—frequent handwashing and social distancing is the key. No one is immune to this disease and we all must stand together to spread awareness and fight for the health of all and for a better tomorrow.

 References

 1.       National Portal of India.

 https://www.mygov.in/covid-19.

 2.       ICMR Guidance for Management of Pregnant Women in COVID-19 Pandemic. https://www.icmr.gov.in/pdf/covid/techdoc/Guidance_for_Management_of_Pregnant_Women_in_COVID19_Pandemic_12042020.pdf .

 3.       World Health Organisation. https://www.who.int/southeastasia/news/detail/10-06-2018-india-has-achieved-groundbreaking-success-in-reducing-maternal-mortality.

 4.       Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health in Low- and Middle-Income Countries. International Perspective of Sexual and Reproductive health Journal 2020. Volume 46 73-76. https://www.guttmacher.org/journals/ipsrh/2020/04/estimates-potential-impact-covid-19-pandemic-sexual-and-reproductive-health

 5.       COVID-19 Impact: Spike in unintended pregnancies in India. https://thecsrjournal.in/covid19-impact-family-planning-india-2020/

 6.       World Health Organization-More than 117 million children at risk of missing out on measles vaccines, as COVID-19 surges. https://www.who.int/immunization/diseases/measles/statement_missing_measles_vaccines_covid-19/en/